Enquiries 1300 655 805
TTY 133 677 Speak and Listen 1300 555 727
Email us via: www.sdro.nsw.gov.au/contact/
Website www.sdro.nsw.gov.au
Payment by Instalments – Individuals
To apply to pay your enforcement order(s) by instalments (or penalty notice(s) if you receive a government benefit).
Your details
First name
Laura
D
0
Date of birth
Licence no.
D
5
M
0
M
4
Y
1
Y
9
Y
7
Lilyfield
Suburb
Lack
Best contact no.
Vehicle rego.
17 Sample Road
Postal address (if different)
Y
2
m
Suburb
Last name
12345678
Current address
pl
e
Note: n Print clearly using BLOCK LETTERS in the space provided and tick the appropriate boxes
n If all sections are not completed, your application cannot be processed
n If you receive a government benefit, you can save the enforcement fee by setting up an instalment plan
by the due date on the penalty reminder notice
n You can organise a payment arrangement yourself through Fines Self Service. Go to www.sdro.nsw.gov.au for more information
n To avoid further enforcement action, please send your completed form to State Debt Recovery Office, PO Box A2571, Sydney South NSW 1235; or fax to (02) 6354 7302; or scan and email us via www.sdro.nsw.gov.au/contact/
0444444444
ABC 123
State
N
S
W
Postcode
2
0
4
0
As above
Sa
Note: Please select preferred contact address:
I wish to pay the following by instalments:
Enforcement Order Number(s)
✔
State
Postcode
Current
Postal
123 456 789
Penalty Notice Number(s) (must be on a government benefit – must sign declaration on next page)
I can afford to pay
$ 30.00
X
.00
per fortnight
Centrelink Reference Number (CRN)
Employer business name
Benefit type
Employer phone no.
AA Packaging Pty Ltd
( 02 ) 9999 8888
Please arrange Centrepay deductions. I have signed the deduction authorisation on the back of this form.
Name of your Bank/Credit Union
Eastpac Bank
Declaration
I have read and completed this form and all details are true and correct.
20 / 03
/ 20 14
L. Lack
Signature
Date
Note: Any information provided may be used by SDRO or provided to third parties with your consent as or
required or permitted by law.
Important: See over the page for more information.
SDR 040 | Payment by Instalments – Individuals | February 2012
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For penalty notices only:
Where I have requested penalty notice(s) be paid by instalment, I confirm I am on a government benefit and understand that by
choosing to pay my penalty notice by instalment I am accepting liability for the offence and waiving my right to seek a review or
choose to go to court about the penalty notice(s) shown. I understand the enforcement fee will not be applied to my penalty but if I
fail to comply with my payment plan, I will be liable for this and any other enforcement related fees.
Signature
Date
/
/
20
Centrepay information
The State Debt Recovery Office (SDRO) can arrange to have your fortnightly instalment payments deducted from your eligible
Centrelink Benefit using the Centrepay program:
n
All Centrelink payments are eligible for the Centrepay Program. Centrepay deductions are voluntary.
Deductions will automatically cease when your instalment arrangement is paid in full.
n If your Centrelink payments are cancelled and/or you stop making payments via Centrepay, you are still required to make your agreed repayments to avoid further enforcement action.
n You must contact SDRO to add new enforcement orders to your payment arrangement. We will then reassess your repayment amounts and advise Centrelink of any changes.
n You can make changes to your Centrepay deductions by contacting SDRO or Centrelink.
nIf you wish to set up Centrepay deductions for your fortnightly instalment payments, read the deduction authorisation and sign
the declaration.
Deduction authorisation
pl
e
n
By authorising centrepay deductions, you are authorising SDRO to advise Centrelink:
n
to make the nominated deduction each fortnight from my current Centrelink payment(s) in respect of my agreement with SDRO
vary the deduction or target amount or suspend the nominated deduction from time to time to ensure my obligations under my
arrangement to pay by instalments are met
n of my correct account or billing number if required.
nto
I give permission for Centrelink to pay the amounts directly to SDRO. I understand that:
n
n
n
n
Sa
it is my choice to have amounts deducted from my Centrelink payment and that I can change or cancel the deduction at any time by contacting SDRO or Centrelink
if I transfer to another eligible Centrelink payment in the future that my current deductions will continue
if I stop using SDRO services but do not stop my Centrepay deduction, SDRO may instruct Centrelink to stop the deduction
Centrelink will notify me in a letter of any changes to my deduction details, including changes requested by SDRO
if deductions from my Centrelink benefits are cancelled for any reason, I am still required to make the agreed repayments on my arrangement to pay by instalments. My consent will be noted on my account record with SDRO.
m
n
Declaration
I have read and completed the information on this form and request that SDRO organise Centrepay deductions on my behalf.
Signature
Date
/
/
20
Privacy statement
Your personal information is protected by law. Centrelink may give your information to SDRO for the purposes of:
n
checking your account number and the amount you want to pay
n
reconciling your payment deduction details.
SDRO may give your personal information to Centrelink for the purposes of:
n
establishing a Centrepay arrangement to make payments by instalments
n
setting a target amount, equal to your current instalment arrangement, for the Centrepay deductions
n
updating deduction or target amounts as required
You may correct or update your personal information by contacting SDRO.
Office of State Revenue: ISO 9001 – Quality Certified | Department of Finance & Services
© State of New South Wales through the Office of State Revenue, 2012. This work may be freely reproduced and distributed for most purposes, however some restrictions apply.
Read the copyright notice at www.osr.nsw.gov.au or contact OSR.
SDR 040 | Payment by Instalments – Individuals | February 2012
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