Emergency Management Regulations 2006

Infringement notice

Emergency Management Act 2005

To:

Address:

Infringement no.

Date of notice

Modified penalty

Due date

Part A: Offence details

Alleged offender:

Alleged offence:

Failure to comply with a direction

Emergency Management Act 2005 s. 86(1)

Location:

Offence date:

Offence time:

Modified penalty:

Issuing officer:

Part B: Take notice

It is alleged you have committed the above offence.

If you do not want to be prosecuted in court for the offence, pay the modified penalty using one of the options shown in Part C below within 28 days after the date of this notice.

If you want this matter to be dealt with by prosecution in court, complete and return the election in Part D below within 28 days after the date of this notice.

If you do not pay the modified penalty within 28 days after the date of this notice, 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 actions 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.

Part C: Payment slip

If paying by post, send this slip with your payment to: [insert details].

Cheques and money orders are to be made payable to [insert details]. Do not send cash in the mail.

Payment must be made in full within 28 days after the date of this notice. No part-payments will be accepted.

Infringement no.

Online and phone payment options

[insert details for paying online or by telephone]

Due date

Amount due

Part D: Court election

I, _____________________ of _____________________ elect to have this matter dealt with by a court. I understand I may receive a summons in due course.

Signature:

Date:

Email:

Phone no:

Once you have completed the details above, return this form within 28 days after the date of this notice, using one of the following options:

[insert options]

Emergency Management Act 2005

Withdrawal of infringement notice

Withdrawal no.

Alleged offender

Name

Address

Details of infringement notice

Infringement no.

Date of issue

Alleged offence

Emergency Management Act 2005 s. 86(1)

Date

Location

Details of offence

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 — Emergency Management Act 2005

[Insert address]

Your signature

Date