Document text
Application for Internal Review of an Infringement Notice
[YOUR FULL NAME]
Current residential address for service of the outcome: [YOUR CURRENT ADDRESS]
[EMAIL] · [PHONE]
[NAME OF THE ENFORCEMENT AGENCY ON THE NOTICE]
[AGENCY'S ADDRESS OR EMAIL FROM THE NOTICE]
[DATE]
Sent by: [EMAIL TO … / POST, POSTAGE RECEIPT … / ONLINE REFERENCE …]
Dear Sir or Madam,
Application for internal review — infringement notice number [NOTICE NUMBER] — section 22, Infringements Act 2006 (Vic)
Offence: [OFFENCE AS SHOWN ON THE NOTICE]
Date of offence: [DATE]
Date of the notice: [DATE]
Due date: [DUE DATE]
Vehicle registration (if any): [REGISTRATION]
I apply for a review of the decision to serve this infringement notice. This is my first and only application for review of this offence. I rely on the following grounds:
( ) Contrary to law (s 22(1)(a)(i)): [EXPLAIN]
( ) Mistake of identity (s 22(1)(a)(ii)): [EXPLAIN, FOR EXAMPLE I WAS NOT THE DRIVER OR IT WAS NOT MY VEHICLE]
( ) Special circumstances (s 22(1)(b)): [DESCRIBE THE CIRCUMSTANCE AND HOW IT LED TO THE OFFENCE]
( ) Exceptional circumstances (s 22(1)(c)): [DESCRIBE WHAT HAPPENED, FOR EXAMPLE A MEDICAL EMERGENCY OR BREAKDOWN]
( ) I was unaware of the notice (s 22(1)(d)): it was not served on me personally and I first became aware of it on [DATE]. This application is made within 14 days of that date.
I ask that the infringement notice be [WITHDRAWN / WITHDRAWN AND REPLACED WITH AN OFFICIAL WARNING].
Under section 24, please suspend enforcement until the review is complete and I have been told the outcome. I note that the review must be decided within the prescribed time of 90 days from receipt of this application (Infringements Regulations 2026, reg 15). Please send the outcome to the address above.
Attached:
Copy of the infringement notice
[EVIDENCE]
[EVIDENCE]
Yours faithfully,
____________________
[YOUR FULL NAME]
For me
[ ] Every ground that applies is ticked — there is no second application
[ ] Sent before the due date: [DATE]
[ ] Date the agency received it: [DATE]; 90 days end: [DATE]
[ ] If the agency asks for more information: reply within 14 days, by [DATE]
[ ] If confirmed: pay or choose another option within 14 days of the outcome notice