( Tick Applicable)	Expiation Notice No.:
PERSON SUBMITTING REQUEST
Full Name:
NOTE: If you are not the Notice Holder you MUST provide the Notice Holder’s Full Name below:-
Notice Holder’s Full Name:
If you are not the Notice Holder the review may be considered, however, generally only the Notice Holder will receive the outcome of the review. If you were the driver of the vehicle at the time of the alleged offence a Statutory Declaration or Driver Nomination from the Notice Holder is required to move the notice to your name before any information can be released to you. Further information regarding expiation notices, statutory declarations, nomination forms and photographic evidence can be found on the SA Police website http://www.police.sa.gov.au.
YOU CANNOT SUBMIT THIS FORM IF YOU HAVE PAID THE NOTICE
THIS FORM IS ONLY TO REQUEST A REVIEW OF THE PHOTOGRAPHIC EVIDENCE FOR A CAMERA OFFENCE
REASON FOR REQUEST
I would like to have the photographic evidence for the above expiation notice reviewed because: -
RED LIGHT OFFENCE:
The vehicle number plate is obscured / not clear
The vehicle number plate is incorrect
The red light is not visible in both photographs
The wrong lane has been captured
SPEED OFFENCE:
The vehicle number plate is obscured / not clear
The vehicle number plate is incorrect
The wrong lane has been captured (fixed traffic camera only)
There is more than one vehicle in the template travelling in the same direction (mobile speed camera only). Refer to your photographic evidence
PREFERRED METHOD OF RESPONSE (tick one option)
I would like the response sent by: -
Email to the Notice Holder at:
Mail to the address on the expiation notice
Mail to Notice Holder at different address
Address:
IF YOUR REASON IS NOT LISTED ABOVE YOU MUST APPLY FOR A REVIEW USING RF2175 – REQUEST FOR REVIEW OF EXPIATION NOTICE
Type name/initials or if printing sign here
Signature:	x	Date:	/	/
(Notice Holder / Person Submitting Request)
Email completed form to:	enb@police.sa.gov.au
OR Post to:	Manager, Expiation Notice Branch GPO Box 2029, ADELAIDE SA 5001