Sch 5Prescribed forms

Schedule 5 — Prescribed forms

[r. 17(5)]

Form 1 — Infringement notice

• Associations Incorporation Act 2015Infringement 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 2015Department of CommerceLocked Bag 14 Cloisters SquarePerth WA 6850In person: Pay the cashier at: Department of Commerce140 William Street Perth WA 6000If 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.