Fillable Infringement Notice - Nomination Statement (Department of Infrastructure, Transport, Cities and Regional Development)

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Infringement Notice - Nomination Statement (Department of Infrastructure, Transport, Cities and Regional Development)

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Infringement Notice - Nomination Statement
If you were not in charge of the motor vehicle or trailer at the time of the alleged offence as shown on the
infringement notice, you will not be liable if before the due date, as shown on that notice, you complete this
Nomination Statement.
If you know the name and address of the person who was driving the motor vehicle or using the trailer at the relevant
time, you should complete these details or, select the appropriate response from the other options shown.
After completing the form, you should sign and date it, and return it to Council.
Infringement number
First name
Surname
Address
I understand that I may be served with a summons to give evidence in relation to this nomination or this offence, and
(Complete Step 1 if the vehicle is registered in a company name, if not go to Step 2.)
Step 1
Position at company
Company name
I am authorised to make this
statement on behalf of the
company
Step 2
I state that at the time of the offence set out in the Notice, I or the company was not the driver or person in
possession or control of the vehicle and I further state that:
I state that at the time of the
offence set out in the Notice, I
or the company was not the
driver or person in
possession or control of the
vehicle and I further state that:
The driver or the person/company in possession or in control of the
vehicle was
The vehicle was permanently disposed of/sold on
I was the driver or company in possession or control of the vehicle
(go to step 3)
Driver's full name or company
name
Driver's or company's address
Driver licence number (if
nominating a person) or ACN/
ABN (if a company)
Issuing Authority if Driver
Licence/Permit was not
issued in Victoria
Date of birth (if nominating a
person) DD/MM/YYYY
Step 3
I have used due diligence, but
do not know or cannot
ascertain the identity of the
actual driver
I have used due diligence, but do not know or cannot ascertain the
identity of the actual driver
I believe that the vehicle or the number plates displayed on the
vehicle were stolen
If nominated as the responsible person in relation to the vehicle, I/
the company was incorrectly identified as the responsible person
and I reject the nomination
Reasons (with the exception
of permanent disposal you are
required to provide reasons
for your statement)
If the information provided in this Statement is not sufficient to identify and locate the nominated person, or if the
person nominated in this Statement rejects the nomination after being issued with an Infringement Notice, the liability
for this offence may remain with you. Further, if you were not the driver of the vehicle at the time of the offence, you
may be obliged to assist Victoria Police in identifying the actual driver of the vehicle at the time of the offence. It is an
offence under the Road Safety Act 1986 to knowingly provide false or misleading information in the Statement.
Penalty: 60 Penalty Units
Signature:
Date:
Upon completion of this form, please return this document intact to: The Local Laws Department, City of Whittlesea,
Locked Bag 1, Bundoora MDC 3083.
Privacy statement
The personal information requested on this form is being collected by Council for the purpose of re-issuing an
infringement notice to the nominated owner/driver of a vehicle. The personal information will be used solely by
Council for that primary purpose or directly related purposes. Council may disclose this information to the person
nominated by you for the purpose of identifying the source of the ensuing infringement notice. If this information is
not collected, Council will proceed with the infringement notice in its present form. The applicant understands that
the personal information provided is for the purpose of re-issuing an infringement notice to the nominated owner/
driver of the vehicle, so that he or she may apply to Council for access to and/or amendment of the information.
Requests for access and/or correction should be made to Council’s Privacy Officer.
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Infringement Notice - Nomination Statement (Department of Infrastructure, Transport, Cities and Regional Development)

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Completed 14 September 2021

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