Sch 5Infringement notice forms

Schedule 5 — Infringement notice forms

[r. 138]

Form 1 ‑ Infringement notice

• Workers Compensation and Injury Management Act 2023INFRINGEMENT NOTICE Infringement notice no.
• Alleged offender Name
• Address
• Details of alleged offence Date or period
• Place
• Written law contravened
• Details of offence
• Date Date of notice
• Authorised officer Name
• Signature
• Modified penalty $_________
• Due date for payment of modified penalty / /20 (Within 28 days after the giving of the notice)
• 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:

__________________________________ / /20 and send this notice to the Approved Officer* at the address below within 28 days after the date of this notice.If you consider that you have good reason to have this notice withdrawn, you can write to the Approved Officer* at the address below requesting that this notice be withdrawn and setting out the reasons why you consider that this notice should be withdrawn. Your letter must be received not later than 28 days after the date of this notice.