NT Police, Fire and Emergency Services
Contact Us
Information Access Team
PO Box 39764
Motor Vehicle Crash
WINNELLIE NT 0821
Application Form
Telephone: (08) 8985 8929
xxxxxx.xxxxxxxxxxx@xx.xxx.xx
Motor Vehicle Crash Reports attract a fee pursuant to the
Police Administration (Fees) Regulations of
50
Revenue Units per report. Revenue Units are governed by the Northern Territory
Revenue Units Act 2009
and are subject to change 1 July each year.
The Northern Territory Department of Treasury and Finance determine the value of a Revenue Unit for all
Northern Territory Government Departments.
Please refer to the current Fee Advice located at the below link if you are unsure of the fee associated with this
request:
http://www.pfes.nt.gov.au/Access-to-information.aspx
Unfortunately, these fees can
NOT be waived under any circumstances.
Please send your completed application form, a clear certified copy of your photo ID and proof of payment to
the Information Access Team by email or mail. If you submit your form at an NT Police Station, the receiving
officer will certify your ID and forward your application to the Information Access Team for you.
Your Name and Contact Details
Title (please circle): Ms / Mrs / Miss / Mr / Dr_________ Postal Address:
First Name:___________________________________ _________________________________________
Family Name:_________________________________ _________________________________________
Phone: (B/H)_____________(A/H)________________ _________________________________________
Email:_______________________________________ Fax:______________________________________
Establishment of Interest
You must tick the applicable involvement type or state a bona fide interest in the information claimed
Driver, Passenger, Motorcyclist, Cyclist or Pedestrian
Owner of Vehicle, Motorcycle, Bicycle, Bus, Truck, Road Train
Other (please specify) __________________________________________________________
Information Required
Copy of the Road Traffic Crash/Incident Report
Copy of a Statement
Crash Details (enter as many fields as you are able)
PROMIS or ICAD Number: __________________________________________________________________
Date of Crash: ___________________________________________________________________________
Place of Crash: ___________________________________________________________________________
Driver/s or Pedestrian/s Unit 1: _______________________________________________________________
Driver/s or Pedestrian/s Unit 2: _______________________________________________________________
Vehicle Registration No/s Unit 1: ______________________Unit 2: _________________________________
Member/Police Station Reported to: ___________________________________________________________
Sign Here ___________________________________
Date _____________________________________
Privacy
Northern Territory Police, Fire and Emergency Services (NTPFES) is collecting this information to ensure that
the correct person is entitled to receive the information requested. This collection is authorised or required by
the
Information Act (NT) and/or the Northern Territory
Police Administration Act. The information provided on
this form is only used to identify the applicant for the purpose of providing the information requested. You have
the right to request access to any of your personal information held by NTPFES. For more information, please
contact NTPFES by telephone on (08) 8985 8926.
This must be completed by the Receiving Officer before forwarding to the Information Access Team
Date Application Received:__________________________________________________________________
Photographic Identification of Applicant At ached: Yes
Receipt Number:_________________________________ Payment Amount:__________________________
Receiving Officer’s Name & Position (please print):_______________________________________________
Signature of Receiving Officer:_______________________________________________________________
Updated: 21 January 2019
NT Police, Fire and Emergency Services
Contact Us
Information Access Team
PO Box 39764
Motor Vehicle Crash
WINNELLIE NT 0821
Payment Options
Telephone: (08) 8985 8929
xxxxxx.xxxxxxxxxxx@xx.xxx.xx
Bank Transfer via Internet or Telephone Banking – only within Australia
Our bank details are:
National Australia Bank (NAB)
Account Name: Receiver of Territory Monies (RTM)
BSB: 085-461
Account Number: 161610000
Description: Applicant’s/Your Name – 131140
You must also attach a copy of the transfer confirmation to this application form and send it to the Information
Access Team at NT Police, Fire and Emergency Services.
Credit Card – this is the only method of payment for overseas customers
Credit card payments can be made to the Receiver of Territory Monies (RTM) over the telephone or by email.
You must advise the RTM that you are paying for a Motor Vehicle Crash Report, with the general ledger code
16JAJA02- 131140 and tax code
N00. You must also attach a copy of the RTM receipt to this application form
and send it to the Information Access Team at NT Police, Fire and Emergency Services.
The RTM can be contacted during office hours on
(08) 8999 1606 or by email
xxxxxxxxx@xx.xxx.xx
Cheque / Money Order
Cheques and money orders should be made payable to the Receiver of Territory Monies (RTM) and sent with
the completed application form to the Information Access Section of NT Police, Fire and Emergency Services.
Updated: 21 January 2019
Document Outline
