I make this solemn declaration conscientiously believing the same to be true, and by virtue of the provisions of the Oaths Act 1900.
Declared at
[place] on [date]
Signature of declarant:
in the presence of an authorised witness, who states:
I,
[name of authorised witness]
a [qualification of authorised witness] :
certify the following matters concerning the making of this statutory declaration by the person who made it:
[* please cross out any text that does not apply]
1.
2.
*I saw the face of the person
*I have known the person for at
least 12 months
*I did not see the face of the person because the person was wearing a face covering, but I
am satisfied that the person had a special justification for not removing the covering, and
OR
*I have not known the person for at least 12 months, but I have confirmed the person's
identity using an identification document and the document I relied on as:
OR
Signature of authorised witness:
Tolling Notice Statutory Declaration – Individuals
Toll Notice number: Vehicle registration number:
I,
[full name of person on toll notice]
of [address]
Phone number:
give notice that the person named below was responsible for the trip:
Catalogue No. 45071725 Form No. 1671 (11/2017) Page 1 of 1
Use this form to give notice of the name and address of the driver who was in charge of the vehicle at the time of the trip.
Print clearly in CAPITAL letters using black pen. Completed form must be received at least 7 days before
the due date on the toll notice. You must provide the name
and address of the person you wish to nominate
Date of birth:
Phone number:
Postcode:Suburb:
Mailing address:
Given name(s):
Surname or Company name:
State:
Company ABN/ACN:
(if applicable)
State/country of issue:
was the driver
responsible for toll
Was the new owner from: Was the previous owner until:
He / she (Please tick appropriate box )
day month year
/ /
Please return this form to:
Toll Compliance Management, Locked Bag 5004, Parramatta NSW 2124
Date:
Roads and Maritime Services (RMS) is collecting your personal information in order to consider your toll objection and may retain it for tolling
purposes. Providing your personal information is voluntary but RMS cannot consider your objection without it. RMS may disclose the details of your
objection and your name and address for the purpose of verifying your objection, including to the person that you have nominated as responsible for
the toll. Otherwise RMS will not disclose your personal information without your consent unless authorised by law. Your personal information will be
held by the RMS at 20-44 Ennis Road, Milsons Point NSW 2061 and generally you can contact RMS to access or correct it.
Privacy statement
day month year
/ /
day month year
/ /
Note: A person who makes a false statement or misleading declaration is liable to a penalty of up to $5,500.
day month year
/ /
day month year
/ /
Toll Notice has been enclosed
The original Toll Notice or a copy must be enclosed.
Legal practitioner / Justice of the Peace [supply JP number]
-
[describe identification document relied on]
UNCLASSIFIED
SENSITIVE: PERSONAL
