LOCAL LAWS – Infringement – Payment plan / extension of time request Infringement – Payment plan / extension of time request 1Introduction2Request You can use this form to Request an infringement payment plan Request an infringement extension of time to pay Please note: This form is a request ONLY. Submissions will be assessed and you will be provided an outcome. Who can use this form Persons who receive an infringement notice from Swan Hill Rural City Council Please note: Council is unable to approve payment plans for infringements from Fines Victoria - You can apply for a payment plan via their website While completing this form, we will request Infringement notice details Contact details Concession card number and expiry (if applicable) Proposed payment plan information It will take about 5 minutes to complete this form. After you submit this form We will send you an email receipt to confirm we have received your request Your request will be assessed by Council Officers and you will be contacted within 7 business days with the outcome If your request is approved a member of staff will contact you for your credit card details (if applicable) to setup the payment plan What happens with your information? Information requested on this form is required by Swan Hill Rural City Council in order to process your application. We will handle any personal information you provide on this form in accordance with the Privacy and Data Protection Act 2014. We record this information on our customer databases and make it available to relevant Council staff in line with our Privacy Statement. You can access your personal information by contacting our Privacy Officer. Request typeSelect request type(Required) Payment plan An extension of time to pay from the specified due date on the notice Infringement detailsSelect infringement type(Required) Animal infringement Parking infringement Local Laws Other Other infringement type(Required)Vehicle registration number(Required)Animal registration number(Required)Infringement notice number(Required)Date of offence Total amount due on notice(Required)Grounds for application(Required) Concession Card Other Type of Concession Card(Required) Centrelink Pensioner Card Centerlink Health Care Card DVA Gold Card Centerlink / DVA Card number(Required)Expiry date(Required)Reason for application(Required)Offender detailsApplication on behalf of(Required) Business Personal This field is hidden when viewing the formBusinessBusiness name(Required)This field is hidden when viewing the formPersonalName(Required)Phone(Required)Include 03 for landline numbersEmail(Required) Residential address(Required) Street Address City / Town State Post Code Postal address(Required) Street Address City / Town State Post Code Untitled Same as residential This field is hidden when viewing the formSection breakExtension of time to paySelect an extension of time from the specified due date on your notice(Required) 1 month 2 months Other Other - Date of proposed extension to pay by(Required) This field is hidden when viewing the formSection breakPayment plan - Proposed paymentsHow will you be paying?(Required) Credit card In person Centrelink Centrepay Please note: A Centrelink Centrepay deduction authority form will need to be completed if your request is approved.Select a schedule(Required) Weekly Fortnightly Monthly This field is hidden when viewing the formFortnightDate of first proposed payment(Required) Proposed payment amount(Required)Please enter a number greater than or equal to 20.(minimum $10 per week)This field is hidden when viewing the formWeeklyDate of first proposed payment(Required) Proposed payment amount(Required)Please enter a number greater than or equal to 10.(minimum $10 per week)This field is hidden when viewing the formMonthDate of first proposed payment(Required) Date each month(Required)Proposed payment amount(Required)Please enter a number greater than or equal to 40.(minimum $10 per week)This field is hidden when viewing the formSection BreakDeclarationDeclaration 1 I declare that I am authorised to make this declaration (Required) Declaration 1 The information provided on this form is complete and correct (Required) Full name
