Prescribed forms

In force

[r. 17(5)]

Form 1 — Infringement notice

Associations Incorporation Act 2015 Infringement notice		Infringement notice no.
Alleged offender	Name: Family name
	Given names
	or Incorporated association name ____________________________________
	Address ________________________________________________ Postcode
Alleged offence	Description of offence _____________________________________
	Associations Incorporation Act 2015 s.
	Date / /20 Time am/pm
	Modified penalty $
Officer issuing notice	Name
	Signature
	Office
Date	Date of notice / /20
Notice to alleged offender	It is alleged that you have committed the above offence. If you do not want to be prosecuted in court for the offence, pay the modified penalty within 28 days after the date of this notice. How to pay By post: Send a cheque or money order (payable to ‘Approved Officer — Associations Incorporation Act 2015’) to: Approved Officer — Associations Incorporation Act 2015 Department of Commerce Locked Bag 14 Cloisters Square Perth WA 6850 In person: Pay the cashier at: Department of Commerce 140 William Street Perth WA 6000 If you do not pay the modified penalty within 28 days, you may be prosecuted or enforcement action may be taken under the Fines, Penalties and Infringement Notices Enforcement Act 1994. Under that Act, some or all of the following action may be taken — your driver’s licence may be suspended, your vehicle licence may be suspended or cancelled, you may be disqualified from holding or obtaining a driver’s licence or vehicle licence, your vehicle may be immobilised or have its number plates removed, your details may be published on a website, your earnings or bank accounts may be garnished, and your property may be seized and sold. If you need more time to pay the modified penalty, you can apply for an extension of time by writing to the Approved Officer at the above postal address.
	If you want this matter to be dealt with by prosecution in court, sign here ______________________________________________ and post this notice to the Approved Officer at the above postal address within 28 days after the date of this notice.

[Form 1 amended: SL 2020/163 r. 4.]

Form 2 — Withdrawal of infringement notice

Associations Incorporation Act 2015 Withdrawal of infringement notice		Withdrawal no.
Alleged offender	Name: Family name
	Given names
	or Incorporated association name _____________________________________
	Address _________________________________________________ Postcode
Infringement notice	Infringement notice no.
	Date of issue / /20
Alleged offence	Description of offence _____________________________________
	Associations Incorporation Act 2015 s.
	Date / /20 Time am/pm
Officer withdrawing notice	Name
	Signature
	Office
Date	Date of withdrawal / /20
Withdrawal of infringement notice [*delete whichever is not applicable]	The above infringement notice issued against you has been withdrawn. If you have already paid the modified penalty for the alleged offence you are entitled to a refund. * Your refund is enclosed. or * If you have paid the modified penalty but a refund is not enclosed, to claim your refund sign this notice and post it to: Approved Officer — Associations Incorporation Act 2015 Department of Commerce Locked Bag 14 Cloisters Square Perth WA 6850 Signature / /20

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