Payment Plan Request

First Name

Last Name

Your Postal Address

Suburb

State

Post Code

Country

Infringement Number

Please separate infringement numbers with a comma. ie 12345,12346,12347...

Agency Name

This is the name of the Council/Hospital/University that issued the infringement. This is never Bartels, Taylor & Associates.

Vehicle Registration Number

Telephone Number

Your email address

Are you the registered owner at VicRoads, nominated driver or have written authority to represent the owner?

Please be advised that only the registered owner of a vehicle can request a review of an infringement. The owner must submit a Known User Statement nominating you as the driver of the vehicle or a letter of authorisation authorising you to represent them for this matter. If you have one of the requested documents from the owner, please attach it below.

I would like

Do you hold a valid concession card?

How many days extension would you like to request?

Frequency of instalment?

Instalment Amount?

Each Payment Plan is different. There are minimum instalment amounts required for payment plans where the owner does not have a valid concession card and also a maximum number of instalments allowed. A good guide is to keep the number of instalments under 15.

Attachments

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I Agree

Acknowledgement

I understand and acknowledge that:

This document is a digitally signed statement.
It is an offence to provide false or misleading information and a penalty may be imposed under the relevant acts.