Sample Payment by Instalments - Individuals

This is a text only version of a Sample Payment by Instalments - Individuals. It is not legal advice.

To see what a completed form could look like, see the pdf version of Sample Payment by Instalments - Individuals (270 kb).

If you need more help, call LawAccess NSW.​

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Email us via: http://www.revenue.nsw.gov.au/contact
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Payment by Instalments - Individuals

To apply to pay your overdue fine(s) by instalments (or penalty notice(s) if you receive a government benefit).

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
• If you receive a government benefit, you can save the enforcement fee by setting up an instalment plan by the due date on the penalty reminder notice
• You can organise a payment arrangement yourself through Fines Self Service. Go to http://www.revenue.nsw.gov.au for more information
• To avoid further enforcement action, 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

Your details

First name. Laura

Last name. Lack

Date of birth. 05 04 1972

Best contact no. 0444444444

Licence no. 12345678

Vehicle rego. ABC 123

Current address. 17 Sample Road

Suburb. Lilyfield

State NSW

Postcode 2040

Postal address (if different) As above

Suburb

State

Postcode

Note: Please select preferred contact address:

Current Postal

I wish to pay the following by instalments:
Overdue Fine Number(s) 123 456 789

Penalty Notice Number(s) (must be on a government benefit - must sign declaration on next page)

I can afford to pay $30.00 per fortnight
Centrelink Reference Number (CRN)

ABN (if applicable)

Employer business name AA Packaging Pty Ltd

Benefit type 

Employer phone no.(02) 9999 8888

Please arrange Centrepay deductions. I have signed the deduction authorisation on the back of this form.

Name of your Bank/Credit Union. Eastpac Bank

Declaration
I have read and completed this form and all details are true and correct.

Signature L. Lack

Date 20/03/2014

Note: Any information provided may be used by State Debt Recovery or provided to third parties with your consent as or required or permitted by law.

Important: See over the page for more information.

For penalty notices only:

Where I have requested penalty notice(s) be paid by instalment, I confirm I am on a government benefit and understand that by choosing to pay my penalty notice by instalment I am accepting liability for the offence and waiving my right to seek a review or choose to go to court about the penalty notice(s) shown. I understand the enforcement fee will not be applied to my penalty but if I fail to comply with my payment plan, I will be liable for this and any other enforcement related fees.

Signature            

Date

Centrepay information

State Debt Recovery (SDR) can arrange to have your fortnightly instalment payments deducted from your eligible Centrelink Benefit using the Centrepay program:

• Most Centrelink payments are eligible for the Centrepay Program. Centrepay deductions are voluntary.
• Deductions will automatically cease when your instalment arrangement is paid in full.
• If your Centrelink payments are cancelled and/or you stop making payments via Centrepay, you are still required to make your agreed repayments to avoid further enforcement action.
• You must contact State Debt Recovery to add new enforcement orders to your payment arrangement. We will then reassess your repayment amounts and advise Centrelink of any changes.
• You can make changes to your Centrepay deductions by contacting State Debt Recovery or Centrelink.
• If you wish to set up Centrepay deductions for your fortnightly instalment payments, read the deduction authorisation and sign the declaration.

Deduction authorisation

For the purpose of this payment plan, I authorise State Debt Recovery to advise Centrelink:

• to make the agreed deduction each fortnight from my current Centrelink payment(s) 
• to vary or suspend the nominated deduction when required to ensure my obligations under my payment plan are met
• of my correct account or billing number if required.

I give permission for Centrelink to pay the amounts directly to State Debt Recovery. I understand that:

• it is my choice to have amounts deducted from my Centrelink payment
• I can change or cancel the deduction at any time 
• if I transfer to another eligible Centrelink payment I need to advise Centrelink that I wish for my repayments to State Debt Recovery to continue
• Centrelink will notify me in writing of any changes to my deductions
  
• if deductions from my Centrelink benefits are cancelled for any reason, I am still required to make the agreed repayments on my payment plan to State Debt Recovery

Declaration

I have read and completed the information on this form and request that State Debt Recovery organise Centrepay deductions on my behalf.

Signature 

Date

Privacy statement

Your personal information is protected by law. Centrelink and State Debt Recovery may share your personal information to fulfil the obligations of your agreed payment plan.

Information about State Debt Recovery's privacy policy can be found on our website at www.sdro.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 040 | Payment by Instalments - Individuals | ​December 2015

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