Sample application that a declaration as a habitual traffic offender be quashed This is a sample. It is important to complete this form with your own details and based on your own circumstances. If you need more help get legal advice. Form 4 Application that declaration as a habitual traffic offender be quashed (Road Transport (General) Act 2005, section 202)

Name of applicant: Hayley Jarrod Residential address: 46 Callum Avenue Tamworth NSW 2340 Postal address: As above Date of birth: 25 May 1984 Licence number: L11223344 Particulars of relevant offences: (Either list the three of more relevant offences (including dates and places of conviction) or attach copy of letter from the Roads and Traffic Authority)

1. Drive with Low Range PCA, 1 February 2010,Tamworth Local Court 2. Drive while disqualified, 7 April 2010, Cessnock Local Court 3. Drive with Low Range PCA, 21 November 2011, Tamworth Local Court

I make application that the declaration having effect on 22 November 2012 (date on which section 28 of Act had effect) that I am a habitual traffic offender be quashed:

There are special circumstances that the court should take into account. My mother suffered a stroke in February 2013 and needs to attend doctor’s appointments on a weekly basis. She is unable to drive and my father works full-time and cannot drive her during the week.

H. Jarrod Applicant

Date: 15 October 2013 Fee paid on Receipt number ______

Notice of hearing

This application has been listed for hearing at the Local Court At: Date: Time:

Registrar of the Local Court Date: To

1 Applicant 2 Roads and Traffic Authority

Note.

Sample only. This is not legal advice. Section 31 provides that the declaration may be quashed by a Court that convicts the person of the relevant offence (at the time of conviction or at a later time). Accordingly the application is to be listed before the Court that has convicted the person of the most recent relevant offence, ie, the offence which gave rise to the declaration as a habitual traffic offender.

Sample only. This is not legal advice.