Application for Withdrawal of Infringement Notice

Please note: A Statutory Declaration may be requested in addition to this form.

Applications can take up to 7 days for processing. Responses will be received via email/post advising you of the outcome.

Application for Withdrawal of Infringement Notice

Infringement Notice Number

Vehicle Registration

Full Name

Full name of the person submitting the declaration

Applicant details

Address

Contact

Type of dispute

I had a medical emergency

My vehicle broke down

I was detained by police

I paid for parking

Other…

Full details of request

If you are at fault due to paying for a different number plate, your infringement will not be withdrawn.

(attach any additional pages, photographs or documents as necessary)

Attachment 1

One file only.
20 MB limit.
Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods, jpg, png, jpeg.

Attachment 2

One file only.
20 MB limit.
Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods, jpg, png, jpeg.

Privacy Statement

City of Darwin complies with Information Privacy Principles contained in the Northern Territory Information Act. These principles protect the privacy of personal information collected, used and stored. It also details how you can access your personal information. Council’s Privacy Statement is available from the City of Darwin, Harry Chan Avenue, Darwin or online.

I hereby certify that the above statements are true and correct to the best of my knowledge and understand that providing false and misleading information is an offence under the Local Government Act 2019 for which the maximum penalty is $74,000 or imprisonment for 2 years.

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