4772GOVERNMENT GAZETTE, WA 12 December 2018

4772 GOVERNMENT GAZETTE, WA 12 December 2018 If you take no action this infringement notice may be registered with the Fines Enforcement Registry after which your driver’s licence or any vehicle licence held by you may be suspended. If the matter is registered with the Registry additional costs will also be payable. If the above address is not your current address, or if you change your address, it is important that you advise us immediately. Failure to do so may result in your driver’s licence or any vehicle licence you hold being suspended without your knowledge. (5) ............................................................. (6) .................................................................................................................................................................. (1) Name of owner or ‘the owner’ (2) Address of owner (not required if owner not named) ———— FORM 4 WITHDRAWAL OF INFRINGEMENT NOTICE Serial No ............................... To: (1) ............................................................................................................................................................. of: (2) .............................................................................................................................................................. Infringement Notice No. .............................................................................. dated .......... / .......... / .......... make: ........................................................................ ; model: ....................................................................... ; registration: .............................................................. , for the alleged offence of ............................................................................................................................... ....................................................................................................................................................................... ....................................................................................................................................................................... ....................................................................................................................................................................... has been withdrawn. The modified penalty of $ ......................................   has been paid and a refund is enclosed.   has not been paid and should not be paid.   delete as appropriate. (3) .......................................................................... (4) .................................................................................................................................................................. (1) Name of alleged offender to whom infringement notice was given or ‘the owner’. (2) Address of alleged offender. (3) Signature of authorised person (4) Name and title of authorised person giving notice ————