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Write Off Application

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This online application is to apply for write-off your overdue fine debt with Revenue NSW.

You can authorise someone else to apply on your behalf such as a relative, solicitor or someone from a community welfare group.

To complete this form you will need to supply:

your full name and any alias, date of birth, address, contact details and driver licence number (if you have one)
An overdue fine reference number
Income details including any Centrelink payments
Information about your current situation
Details about expenses and assets

You will need to attach documentary evidence to support your application. Evidence may include:

copies of your payslips, Centrelink statements or other evidence of your income
copies of your bank account, credit union or building society statements for the last three months
evidence of expenses
report from a doctor or psychologist explaining any medical condition
report from a case worker, social worker or other professional confirming domestic problems
police reports or court documents to confirm situation

Provide as much supporting documentation as you can to assist Revenue NSW in understanding your situation. Have this ready before you start as you cannot save a partially completed application.

Providing a false or deliberately misleading statement may lead to prosecution under Section 307A of the Crimes Act 1900.

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Note: All fields marked with asterisk () are mandatory. To submit your application, you must attach all supporting documentation listed in your application.

Application type

I am applying for a write off:

I am applying for a write off

For debts in my name On behalf of someone else

The debt is in the name of:

The debt is in the name of

A company, organisation, business, trust, or other legal entity A natural person or persons

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Your information

Your own information (not the person you are applying on behalf of)

Person or company

Choose person or company: percomp

title

Title: title

first name

First name: firstname

last name

Last name: lastName

company name

Business name: businessName

AbnnAcn

ABN/ACN: abnAcn

contact title

Title: contactTitle

contact first

Contact first name: contactFirst

contact last

Contact last name: contactLast

position

Position: position

Date of birth

Date of birth:

Email:

Disclaimer: Information you supply on this form may be provided to third parties with your consent or as required or permitted by law. Revenue NSW will correct or update your personal information at your request. Read more about privacy at www.revenue.nsw.gov.au

Organisation name (if applicable):

What is your relationship to the person you are applying on behalf of?:

Phone number

Phone number:

Address

Please enter residential address only

Country

Country:country list

Address line 1

Address line 1:Address line 1

Address line 2

Address line 2:

Suburb/State/Postcode

Suburb/State/Postcode:Suburb/State/Postcode

Overseas address

Address:overseasResAddr

Mailing address

The same as the address above

Mailing country

Country:country list

Mailing address 1

Address line 1:Street address line 1

Mailing address 2

Address line 2:

Mailing Suburb/State/Postcode

Suburb/State/Postcode:Suburb/State/Postcode

Mailing overseas address

Address:overseasResAddr

Preferred contact method:

Preferred contact

Email Mail Phone

If we are unable to contact you via telephone, we will respond to your request by email. Please ensure your contact details are correct.

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Your information

Person or company

Choose person or company: percomp

title

Title: title

first name

First name: firstname

last name

Last name: lastName

company name

Business name: businessName

AbnnAcn

ABN/ACN: abnAcn

contact title

Title: contactTitle

contact first

Contact first name: contactFirst

contact last

Contact last name: contactLast

position

Position: position

Date of birth

Date of birth:

Email:

Disclaimer: By providing your email address to our office you are consenting to receive notifications and other information via email, this may include but is not limited to arrears notifications, alerts of new fines, due dates and payment information. You can change these preferences at any time by contacting us.

Phone number

Phone number:

Address

Please enter residential address only

Country

Country:country list

Address line 1

Address line 1:Address line 1

Address line 2

Address line 2:

Suburb/State/Postcode

Suburb/State/Postcode:Suburb/State/Postcode

Overseas address

Address:overseasResAddr

Mailing address

The same as the address above

Mailing country

Country:country list

Mailing address 1

Address line 1:Street address line 1

Mailing address 2

Address line 2:

Mailing Suburb/State/Postcode

Suburb/State/Postcode:Suburb/State/Postcode

Mailing overseas address

Address:overseasResAddr

Preferred contact method:

Preferred contact

Email Mail Phone

If we are unable to contact you via telephone, we will respond to your request by email. Please ensure your contact details are correct.

Are you known by other name?:

Are you known by other name?

Yes No

Your other names:

Name

Alias 1:

Name

Alias 2:

Name

Alias 3:

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Write off Grounds

The answers should be about the person named on the overdue fine(s)

Write off application grounds?:

Write off Grounds

Financial Medical Domestic Combination of the above

If applying under Financial grounds, you must supply the following documentation:

The last 3 months of bank statements for all your banks accounts.
Details and evidence of Income for you and your dependents (if applicable).
Details and evidence of Expenses and Assets.

You will be advised what specific evidence is needed for 'Income, Assets and Expenses' later in the form.

If applying under Medical Grounds, you must supply the following documentation:

Letter or report from a Doctor. hospital or health care worker. This cannot be older than 6 months
The last 3 months of bank statements for all your banks accounts
Details and evidence of Income for you and your dependents (if applicable)
Details and evidence of Expenses and Assets

You will be advised what specific evidence is needed for 'Income, Assets and Expenses' later in the form.

If applying under Domestic Grounds, you must supply the following documentation:

The last 3 months of bank statements for all your banks accounts
Letter or report from a community welfare group explaining your current problems, such as Salvation Army, Mission Australia
Details and evidence of Income for you and your dependents (if applicable)
Details and evidence of Expenses and Assets

You will be advised what specific evidence is needed for 'Income, Assets and Expenses' later in the form.

If applying under multiple Grounds, you must supply the following documentation:

Letter or report from a Doctor, hospital or health care worker. This cannot be older than 6 months
Letter or report from a community welfare group explaining your current problems, such as Salvation Army, Mission Australia
The last 3 months of bank statements for all your banks accounts
Details and evidence of Income for you and your dependents (if applicable)
Details and evidence of Expenses and Assets

You will be advised what specific evidence is needed for 'Income, Assets and Expenses' later in the form.

Type of debt:

Type of debt

Fines Fees Taxes Grants/Duties/Levies

Has a Work & Development Order (WDO) been considered?:

Has a Work & Development Order (WDO) been considered?

Yes No

Explain why a WDO is not suitable’

Explain why a WDO is not suitable:

Hint, lack of WDO service providers in my area, transport issues, WDO sponsor does not cater for my activity, cannot commit to WDO

Tell us why not

Tell us why not:

Hint, do not know what a WDO is, do not know how to apply, not suitable

Reference number(s):

Reference Number

Reference number 1:

Reference Number

Reference number 2:

Reference Number

Reference number 3:

Reference Number

Reference number 4:

Reference Number

Reference number 5:

Reference Number

Reference number 6:

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Financial position - Income

The following questions relate to income and must be completed regardless of the write off grounds.

The answers should be about the person named on the overdue fine(s).

The application cannot proceed unless accurate and reasonable information is listed.

What is your main source of income?:

What is your main source of income?

Employed Self-employed Receiving a government benefit Receiving other income Not receiving any income

Employer:

Self-employment details (name of business):

Benefit type:

Description of other income:

How are you being financially supported?:

Other people in your household

Name

Name:

Date of birth

Date of birth:

Relationship

Relationship:

Name

Name:

Date of birth

Date of birth:

Relationship

Relationship:

Name

Name:

Date of birth

Date of birth:

Relationship

Relationship:

Name

Name:

Date of birth

Date of birth:

Relationship

Relationship:

Income after tax - fortnightly

Please enter '0' where applicable.

column 1	You ($)	Your partner (if applicable) ($)	column 1
Net wage / salary (after tax) Evidence needed: 3 most recent payslips	netWageYou	netWagePartner	column 1
Sole trader / self employed income Evidence needed: Recent profit/loss statement and most recent tax return	soleTraderYou	soleTraderPartner	column 1
Centrelink benefit including Family Tax benefit A&B Evidence needed: Current Centrelink Statement	centrelinkFamBenefitYou	centrelinkFamBenefitPartner	column 1
Business / partnership income Evidence needed: Operating statement for the last full quarter showing business income and expenditure	busPartnerIncomeYou	busPartnerIncomePartner	column 1
Child support Evidence needed: Most recent Child Support Statement	childSupportYou	childSupportPartner	column 1
Rental / board income Evidence needed: Evidence of Income from rent or board that you receive	rentalIncomeYou	rentalIncomePartner	column 1
Workers compensation, sickness or accident insurance payments Evidence needed: Most recent statement from your insurance provider or proof of payments	workersCompYou	workersCompPartner	column 1
Income from any shares Evidence needed: Evidence of income from any shares that you received a dividend from	incomeFromSharesYou	incomeFromSharesPartner	column 1
Other income Evidence needed: Relevant documentary evidence	otherIncomeYou	otherIncomePartner	column 1
TOTAL INCOME	$0.00 totalIncomeYou	$0.00 totalIncomePartner	column 1
column 1	GRAND TOTAL	$0.00 totalIncome	column 1

At least one field required.

Cancel

Financial position - Expenses

The following questions relate to expenses and must be completed regardless of the write off grounds.

The answers should be about the person named on the overdue fine(s).

The application cannot proceed unless accurate and reasonable information is listed.

Expenses - fortnightly

Please enter '0' where applicable.

column 1	Amount paid ($)	Paid to?	Balance remaining ($)
Mortgage repayments Evidence needed: Most recent mortgage statement	mortgageAmt	mortgageOwedTo	mortgageBalance
Rent or board Evidence needed: Detailed rental statement or letter from landlord listing rental details	rentBondAmt	rentBondOwedTo	rentBondBalance
Car loan / lease Evidence needed: Most recent car agreement or loan/lease statement for each vehicle	carLoanAmt	carLoanOwedTo	carLoanBalance
Food / groceries	foodGroceriesAmt	foodGroceriesOwedTo	foodGroceriesBalance
Electricity / gas Evidence needed: Most recent utility account	electricityGasAmt	electricityGasOwedTo	electricityGasBalance
Phone Evidence needed: Most recent phone bill	phoneAmt	phoneOwedTo	phoneBalance
Clothing	clothingAmt	clothingOwedTo	clothingBalance
Rates (council and water) Evidence needed: Most recent council and water rates account	ratesAmt	ratesOwedTo	ratesBalance
Fares / fuel	faresFuelAmt	faresFuelOwedTo	faresFuelBalance
Motor vehicle expenses	motorVehicleExpenseAmt	motorVehicleExpenseOwedTo	motorVehicleExpBalance
Insurance	insuranceAmt	insuranceOwedTo	insuranceBalance
Voluntary superannuation contributions	voluntatySuperAmt	voluntatySuperOwedTo	voluntatySuperBalance
Health fund contributions	healthFundAmt	healthFundOwedTo	healthFundbalance
Medical / medication expenses Evidence needed: Evidence of medical bills or regular medications for yourself or your dependants	medicalExpenseAmt	medicalExpenseOwedTo	medicalExpBalance
Personal loan repayments Evidence needed: Most recent personal loan statement	loanDebtRepaymentAmt	loanDebtRepaymentOwedTo	loanDebtBalance
Credit card repayments Evidence needed: Most recent credit card statement for all credit cards you have	creditcardRepaymentAmt	creditcardRepaymentOwedTo	creditcardBalance
Store cards	storeCardsAmt	storeCardsOwedTo	storeCardsBalance
Deferred purchases e.g Zippay, Afterpay	deferredPurchaseAmt	deferredPurchaseOwedTo	deferredPurchaseBalance
Taxation or other government debt repayments	taxGovtDebtAmt	taxGovtDebtOwedTo	taxGovtDebtBalance
Centrelink loan / debt repayments Evidence needed: Current Centrelink statement	clinkDebtRepaymentAmt	clinkDebtRepaymentOwedTo	clinkDebtBalance
School / education expenses	schoolExpensesAmt	schoolExpensesOwedTo	schoolExpensesBalance
Child support Evidence needed: Most recent child support statement	childSupportAmt	childSupportOwedTo	childSupporBalance
Entertainment	entertainmentAmt	entertainmentOwedTo	entertainmentBalance
Child care Evidence needed: Last month of child care receipts	childcareAmt	childcareOwedTo	childcareBalance
Other expenses	otherExpenseAmt	otherExpenseOwedTo	otherExpenseBalance
FORTNIGHTLY TOTAL EXPENSES	$0.00 totalExpenditure	column 1	$0.00 totalExpenditure

At least one field required.

If you declared 'other expenses' or if any expenses are unusually large, please provide a further explanation here:

Cancel

Financial position - Assets

The following questions relate to Assets and must be completed regardless of the write off grounds.

The answers should be about the person named on the overdue fine(s).

The application cannot proceed unless accurate and reasonable information is listed.

Assets (what you own)

Please enter '0' where applicable.

column 1	Asset particulars (e.g address)	Market value or total $
House and land (primary residence)	houseLandDetails	houseLandVal
Other real estate (provide address)	otherRealEstateDetails	otherRealEstateval
Motor vehicle (make / model)	motorVehicleDetails	motorVehicleVal
2nd motor vehicle (make / model)	motorVehicleDetails2	motorVehicleVal2
Caravan / trailer	caravanTrailerDetails	caravanTrailerVal
Boats	boatDetails	boatVal
Household furniture	houseFurnitureDetails	houseFurnitureVal
Electrical goods	electricalGoodsDetails	electricalGoodsVal
Shares (details)	sharesDetails	sharesVal
Superannuation balance	superannuationDetails	superannuationVal
Investments (details)	investmentDetails	investmentVal
Assets held outside Australia	assetsOutAUDetails	assetsOutAUVal
Other assets	otherAssetsDetails	otherAssetsVal
TOTAL ASSETS	column 1	$0.00 totalAssets

At least one field required.

If you declared 'other assets' or if you wish to make a statement about any significant assets listed above, please provide a further explanation here:

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Other information, checklist & declaration

Can any money be paid towards the debt?:

Can any money be paid towards the debt?

Yes No

Payment Preference:

How much?:

Please provide any further information that will help support your application:

TIP: Use this area to explain your previous, current and future situation

Is all the required documentation available?:

Is all the required documentation available?

Yes No

Please advise why documentation is not available:

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Supporting documentation

Acceptable file types are: .zip; doc; docx; xls; xlsx; jpg; jpeg; png; gif; tif; tiff; pdf and txt with a maximum file size of 5 MB and total upload size of 20 MB per submission.

Choose file...testing

Checklist

Please tick:

checklist

Full name and address supplied Contact details supplied Attached bank statements Completed income section and attached evidence Completed expenses section and attached evidence Completed asset section Provided employment details (if applicable) Attached letters/reports from doctors, social Worker, or community groups Police report or court documents attached (if applicable) Listed other people in your household

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Privacy statement

Information collected from you for the purpose stated on this form may be provided to third parties with your consent or as required or permitted by law. Revenue NSW will correct or update your personal information at your request. Read more about privacy at www.revenue.nsw.gov.au

Enter the message as it is shown:

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Please wait while verifying uploaded file.

A write off application can only be considered for debts in the name of a natural person. Contact Revenue NSW to discuss your options.