Infringement notice forms
Schedule 5 Infringement notice forms
[r. 26]
Form 1 — Infringement notice
Building and Construction Industry (Security of Payment) Act 2021
INFRINGEMENT NOTICE
Infringement notice no.
Alleged offender
Name
Address
Alleged offence
Date or period
Time
Place
Details of offence
Written law contravened
Date
Date of notice
Issuing officer
Name
Office
Signature
Modified penalty
$
TAKE NOTICE
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 to the Approved Officer within 28 days after the date of this notice.
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 should contact the Approved Officer at the address below.
Paying the modified penalty will not be regarded as an admission for the purposes of any civil or criminal court case.
If you want this matter to be dealt with by prosecution in court, sign and date here:
__________________________________ / /
and post this notice to the Approved Officer at the address below within 28 days after the date of this notice.
How to pay
By post
Tick the box below and post this notice to:
Approved Officer — Building and Construction Industry (Security of Payment) Act 2021
[Address]
🗆 I want to pay the modified penalty. A cheque or money order (payable to ‘Approved Officer’ — Building and Construction Industry (Security of Payment) Act 2021) for the modified penalty is enclosed.
In person
Pay the cashier at:
[Address]
Method of service
Date of service
Form 2 — Withdrawal of infringement notice
Building and Construction Industry (Security of Payment) Act 2021
WITHDRAWAL OF INFRINGEMENT NOTICE
Withdrawal no.
Alleged offender
Name
Address
Details of infringement notice
Infringement notice no.
Date of issue
Alleged offence
Date or period
Time
Place
Details of offence
Written law contravened
Approved Officer withdrawing notice
Name
Office
Signature
Date
Date of withdrawal
Withdrawal of infringement notice
[*Delete whichever is not applicable]
The above infringement notice issued against you for the above alleged offence 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, you may claim your refund by signing and dating this notice and posting it to:
Approved Officer — Building and Construction Industry (Security of Payment) Act 2021
[Address]
Your signature
Date
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