Revised: 17/05/2018 Page 1

RF1442

SPEED / RED LIGHT STATUTORY DECLARATION

WARNING: The Oaths Act 1936 provides a maximum penalty of 4 years imprisonment for any person who knowingly makes a Statutory Declaration which is untrue in any regard.

WARNING: Under s79B(6a) of the Road Traffic Act 1961, SA Police must provide your name to the person you have nominated on this statutory declaration. SA Police must not provide your address. However, the nominated person might later obtain a copy of your statutory declaration.

WARNING: If this Statutory Declaration is not accepted by the issuing authority at any time, responsibility may return to you and an enforcement warning notice may be issued to you – additional fees apply.

SEND COMPLETED DECLARATION to the Manager, Expiation Notice Branch,

GPO Box 2029, Adelaide SA 5001 Or email to DriverNomination@police.sa.gov.au

DO NOT SEND OR MAKE PAYMENT – A NEW NOTICE WILL BE ISSUED TO THE NOMINATED DRIVER

This Declaration must be completed by the person the notice is issued to; It must be witnessed by a Justice of the Peace or a person proclaimed under Part V of the Oaths Act 1936 (e.g. legal practitioner,

a proclaimed police officer); Responsibility for payment will remain with the owner if this Declaration is not properly completed and submitted to the

Commissioner of the South Australia Police on or before the due date for payment of the notice.

I, Daytime Phone No.: (Full Name) of (Address)

authorised to speak for Company Name:

(if applicable)

do solemnly and sincerely declare that at the time of the offence referred to in Expiation Notice No.:

issued to Motor Vehicle Registration Number: State:

The vehicle was ( Cross applicable)

driven by another person whose details are listed below; or sold to the person / company whose details are listed below; or hired to the person / company whose details are listed below; or

I am unable to ascertain the identity of the driver of the vehicle at the time of the alleged offence. The enquiries I have made to identify the driver are: (attach an additional page if necessary – must be sighted and witnessed)

Full Name:

Address: (Full Residential Address) (Postal Address – if same as above, write ‘AS ABOVE’) Drivers Licence No.: State of Issue: Date of Birth: / /

Date Vehicle Sold: / / Date of Hire: (from) / / (to) / /

and I make this solemn declaration conscientiously believing the same to be true, and by virtue of the Oaths Act 1936.

Declared and subscribed at: in the State of:

Signature: (person making declaration)

Justice of the Peace Proclaimed Police Officer Commissioner for taking affidavits

Declared before: Name & ID:

Signature: Date: / /

FOR OFFICE USE ONLY:

(Email)

in possession of the person/company whose details are listed below; or