Sample Payment by Instalments - Companies
This is a text only version of a Sample Payment by Instalments - Companies. It is not legal advice.
To see what a completed form could look like, see the pdf version of
Sample Payment by Instalments - Companies 
(238kb).
If you need more help, call
LawAccess NSW.
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TTY 133 677 Speak and Listen 1300 555 727
Email us via:
http://www.revenue.nsw.gov.au/contact
Website http://www.revenue.nsw.gov.au
Payment by Instalments - Companies
To apply to pay your fine by instalments.
Note:
- Print clearly using BLOCK LETTERS in the space provided and tick the appropriate boxes
- If all sections are not completed, your application cannot be processed
- Please send your completed form to State Debt Recovery, PO Box A2571, Sydney South
NSW 1235; or scan and email us via
http://www.revenue.nsw.gov.au/contact
Company details
Company name. HA Packaging Pty Ltd
ABN 1234567890
Best contact no. 9999 8888
Mailing address. 1/141 Sample Road
Suburb Lilyfield
State NSW
Postcode 2040
Trading address As above
Suburb
State
Postcode
Overdue Fine No. 123456789
Is the company currently trading? Yes No
Name of company Bank/Credit Union. Eastpac Bank
Do you own vehicles? Yes No
Rego no(s) ABC 123 and XYZ 789
How much can the company afford to pay per fortnight? $ 40.00
Declaration
The information contained is true and correct and I am authorised by the company to complete this document.
Name Harry Anderson
Position Director
Signature H. Anderson
Date 20/03/2014
Privacy statement
Information collected from you for the purpose stated on this form may be provided to third parties with your consent or as required or permitted by law. OSR will correct or update your personal information at your request. Read more about privacy at
www.osr.nsw.gov.au
Office of State Revenue: ISO 9001 - Quality Certified | Department of Finance, Services and Innovation
State of New South Wales through the Office of State Revenue, 2015. This work may be freely reproduced and distributed for most purposes, however some restrictions apply. Read the copyright notice at
www.osr.nsw.gov.au or contact OSR.
SDR 043 | Payment by Instalments - Companies | December 2015