Section 1 Applicant Details

Please complete all sections below to have your Infringement reviewed. Only one Internal Review may be submitted per Infringement Notice.

You are: *

Infringement was issued on the vehicle. I was the driver of the vehicle on the date and time of offence and would like to nominate myself as the driver.Person named on the infringement.Other person with consent.Authorised Company Representative.

Name of Applicant

OR Corporation Name

Postal Address *

Telephone *

Email Address *

Section 2 - Infringement Details

Please complete a separate form for each infringement you wish to have reviewed.

Infringement Number *

Infringment Type *

Other

Section 3 - Grounds for Application

Please check the relevant box (See descriptions below) *

Exceptional Circumstances (See description 1 below)Contrary to Law (See description 2 below)Special Circumstances (See description 3 below)Mistaken Identity (See description 4 below)Person Unaware of Fine (See description 5 below)Penalty Reminder Fee/Prescribed Costs Waiver Request Note: Original penalty remains applicable (See description 6)

Description of Relevant Grounds for Internal Review Appeal

1. Exceptional Circumstances
Please provide details of the exceptional circumstances (where you have committed the offence due to unforeseen or unpreventable circumstances, e.g. medical emergencies).

2. Contrary to Law
Please provide the reasons why you consider the decision to issue you with an Infringement was unlawful (e.g. the Infringement was not valid).

3. Special Circumstances
Special circumstances includes:

A mental or intellectual disability, disorder, disease or illness
A serious addiction to drugs, alcohol or volatile substance
Homelessness
Family violence within the meaning of the Family Violence Protection Act 2008, or
A long-term circumstance or condition making it impracticable to deal with the fine.

You must provide evidence (e.g. letter, report, statement) from one of the following parties to support you application:

A case worker, case manager or social worker
A general practitioner, psychiatrist or psychologist, or
An accredited drug treatment agency.

Evidence (e.g. letter, statement or a report) from practitioner or case worker should include the following information:

The practitioner/case worker’s qualification and relationship with you, including the period of engagement
The nature, severity and duration of your condition or your circumstances
Whether, in the opinion of the practitioner/case worker, your condition/circumstances:
a) Contributed to a significantly reduced capacity to understand or control the conduct constituting the offence, or
b) Make it impracticable to deal with your fine

For more information, visit www.fines.vic.gov.au

4. Mistaken Identity
Please provide an explanation of why you rely on the ground of mistake of identity (including evidence e.g. copy of your driver’s licence, in support).

5. Person Unaware of Fine
An application made on the ground of ‘person unaware’ must:

Be made within 14 days of you becoming aware of the infringement notice (You may evidence the date that you became aware of the infringement notice by executing a statutory declaration)
State the grounds on which the decision should be reviewed
Provide your current address for service.

6. Penalty Reminder Notice Additional Costs Waiver Request
Please provide the reason/s why you believe the Penalty Reminder Notice Additional Costs should be waived. Note: The original penalty amount is still applicable under this request.

Applicants please note: If you do not provide sufficient information, the enforcement agency may request further information. If you do not provide this further information within 28 days of the date of request, the enforcement agency may determine the application without the further information.

Explain circumstances/grounds for your application here:

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By checking this box I understand that this is the only Internal Review for this Infringement that I am able to submit pursuant to s.22 (2) (e) of the Infringements Act 2006. *

Consent for Internal Review

Name (person named on the infringement)

Of (address of person named on the infringement)

Give my consent to (name of person making the application on your behalf)

to apply for an Internal Review on my behalf in relation to Infringement Number

Please check box to agree (for person named on the infringement): *

Please check box to agree (other person with consent): *

I acknowledge Wellington Shire Council's Privacy Statement. *