Application for Withdrawal of Infringement Notice

Please review Infringement and Appeals before submitting this form.

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.

Infringement Notice Number

Vehicle Registration

Full Name

Full name of the person submitting the declaration

Address

Contact

Full details of request

(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

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