Please list your Traf¿c Infringement Notice Number AND your Obligation Number.
Traf¿c Infringement Notice Number

Obligation Number

X Go to Part 1 or Part 2

Complete PART 1 Only:
Complete PART 2 Only:

PART 1:
A

To nominate the driver/owner of the vehicle
To have the matter heard and determined in Court

NOMINATION STATEMENT

Please list your name and address details and then X Go to B
Full Name

Corporation Name and ACN/ABN (if applicable)

Address

State

B

Postcode

I state that I was not in possession or control of the vehicle at the time of the offence alleged in the Traf¿c Infringement Notice (notice number as above) because (please 8 whichever statement applies):

Statement 1

Statement 2

Statement 3

Statement 4

Statement 5

Someone else was the driver or the person/ corporation in possession or control of the vehicle at the time of the offence.

I sold/permanently disposed of the vehicle to someone else on

I believe the vehicle or the number plates displayed on the vehicle were stolen.
Please attach Police
Report.

I do not know and cannot identify the driver or person in possession or control of the vehicle at the time of the offence.

If nominated as the responsible party in relation to the vehicle,
I/the corporation was incorrectly nominated and
I reject the nomination.

/
D D

X Go to C

C

/ 20
M M

Y Y Y Y

X Go to C

X Go to E

X Go to D

X Go to D

If you selected Statement 1 or 2 above, list the details of the person who was driving or in possession or control of the vehicle at the time of the offence.
Family name / Corporation name

First name / Corporation ACN/ABN

Address of person / Corporation

State

State / Country of issue

Driver Licence / Permit Number

Postcode

Date of birth

Taxi DC number (if applicable)

/
D D

/ 19
M M

Y Y Y Y

X Go to E

If you do not provide a Driver Licence number or date of birth, this statement will be rejected.

D

If you selected Statement 4 or 5 above, tell us what reasonable and diligent enquiries you’ve made to try to identify the driver or person in possession or control of the vehicle at the time of the offence OR if you/the