APPLICATION FOR PAYMENT ORDER
Infringements Act 2006, section 76
APPLICATION: (please tick one)
TO PAY BY INSTALMENTS
OR
FOR ADDITIONAL TIME TO PAY
APPLICANT’S DETAILS (please print in capital letters)
Full Name: ____________________________________________________ Date of Birth: ___ / ___ / _______
Previous Names: ________________________________________________ Driver Licence Number: _________
(eg Maiden name)
Residential Address: ______________________________________________________ Postcode: ___________
Postal Address: __________________________________________________________ Postcode: ___________
Previous Addresses: __________________________________________________________________________
Phone (Home): _____________________ (Work): _____________________ (Mobile): ____________________
All Vehicle Registration Numbers: _______________________________________________________________
Reference Number/s:
_____________________________________________________________
(eg Obligation, Case Number or Warrant Number)
IF THE COURT IDENTIFIES FURTHER UNPAID FINES IN YOUR NAME, IT IS ASSUMED THAT YOUR
APPLICATION ALSO APPLIES TO THOSE MATTERS
I hereby make application for a payment order to pay by instalments/for additional time to pay pursuant to section 76 of the
Infringements Act 2006 and state that the following information is true and correct
Do you have an existing payment order to pay by instalments?
(please tick one)
NO
YES
If you have ticked YES, please provide current Instalment Payment Plan Number: ______________________
If you have failed to comply with a previous payment arrangement in the past, please supply reasons here:
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
EMPLOYMENT/INCOME DETAILS
Occupation:
______________________________________________________________________________
Employer:
______________________________________________________________________________
(including address)
Net Wages:
$_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
(fortnightly)
Other Income: $_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
(eg rental income, investments)
BENEFIT DETAILS
Benefit/Pension type:
______________________________________________________________________
(eg Newstart)
Benefit/Pension Number: ______________________________________________________________________
(eg Centrelink Customer Reference Number (CRN))
Amount received fortnightly: $_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Please note: If you indicate that you are currently receiving benefits from Centrelink you may be able to have
instalments directly debited from your fortnightly income.
FORTNIGHTLY EXPENSES
Rent/Mortgage/Board: (please circle)
Food:
Electricity/Gas/Telephone:
Car Expenses:
Public Transport:
Medical Expenses:
ASSETS & LIABILITIES
Property
House:
Car:
Other property:
Other debts:
$
$
$
$
$
$
___________
___________
___________
___________
___________
___________
Other Expenses: (give details)
_______________________________
_______________________________
_______________________________
_______________________________
Total Fortnightly Expenses:
Value
$ ________________________
$ ________________________
$ ________________________
$ ________________________
$ ______________
$ ______________
$ ______________
$ ______________
$ ____________
Amount owed
$ _________________________
$ _________________________
$ _________________________
$ _________________________
(eg Credit cards, personal loans)
07/06
STATE THE REASONS WHY YOU WISH TO MAKE THIS APPLICATION
Please provide any exceptional circumstances you would like to be considered for this application and attach
any supporting documentation.
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
You can apply to either extend the due date or pay by regular instalments of an agreed amount.
PAYMENT ORDER APPLICATION:
TO PAY BY INSTALMENTS
I would like to pay by instalments of $_________ every fortnight/month (please circle one)
starting on ____ /____ /____
(no more than 28 days from date of application).
OR
ADDITIONAL TIME TO PAY
I will pay the full amount due by ____ /____ /____
(not more than 3 months from the date of application).
WARNING: If your application is granted and you do not make each instalment payment by the
due date, the Court will issue a warrant for the full amount owing against each outstanding
enforcement order applicable and you may incur additional costs.
REMEMBER: It is your responsibility to ensure that each payment is made on or before the due
date.
Please note - Before submitting this application to the Infringements Registrar, please check to
ensure that all relevant sections as they apply to you have been completed.
*IMPORTANT*
Penalties for making a false or misleading statement apply.
If the Infringements Registrar finds a statement to be false or misleading, any existing payment
order may be cancelled. Furthermore, a penalty of 10 penalty units applies for giving a false or
misleading statement, pursuant to section 167 of the Infringements Act 2006.
I declare that the information contained in this written statement is true and correct.
SIGN HERE ________________________________________________
Dated ____ /____ /____
The person named in the Enforcement Order MUST sign this written statement and all attached documents.
POST TO:
THE INFRINGEMENTS REGISTRAR
INFRINGEMENTS COURT
PO BOX 14487
MELBOURNE VIC 8001
07/06