Crimes Act 1900—Form 5
(see s 357)
List of other alleged offences
Office of the Director of Public Prosecutions
Canberra, ACT
To	
charged with	
	
Memorandum for accused’s information
(1)	The list on the back of this form gives particulars of............other offences that you are alleged to have committed.
(2)	If you are convicted of the charge of..............firstmentioned above, you may before sentence is passed, if the presiding judge or magistrate so decides and the prosecutor consents, admit all or any of the other offences set out on the back of this form and ask that any of those offences that you have admitted be taken into account by the presiding judge or magistrate in passing sentence on you.
(3)	If you are convicted and the presiding judge or magistrate does take any of the other offences that you have admitted into account, the maximum sentence that may be imposed on you will nevertheless be the maximum sentence for the offence of .....................firstmentioned above.
(4)	No further proceedings may be taken against you in relation to the other offences taken into account unless your conviction for the offence of.......................firstmentioned above is set aside or quashed.
(5)	If proceedings are taken in the circumstances mentioned in item (4) or if the presiding judge or magistrate does not for any reason take any 1 or more of the other offences that you have admitted into account, your admission cannot be used as evidence against you in any proceedings taken in the circumstances mentioned or taken in relation to the offences not taken into account.
Signature of the Director of Public Prosecutions, or of a person authorised in writing by him or her	

Date	

Signature of accused acknowledging receipt of copy of this document 	

Date	
Certificate
In sentencing.........................for the offence of.....…….......today, I have taken into account the following offences alleged against and admitted by him or her, that is to say, the offences numbered........................in the list on the back of this form.
Dated:

Judge of the Supreme Court 
or Magistrate of the Magistrates Court

[back of form]
Number	Place where offence was committed	Date of 
offence	Offence(s) 
(Brief description)	Whether or 
not committed for trial?
Yes or No	

Endnotes
1	This form was originally in the Crimes Act 1900, schedule 6.  Under amendments made by the Legislation (Consequential Amendments) Act 2001, the form was omitted from that schedule and became a form approved under the Crimes Act 1900, section 443 (see amdts 1.1006 and 1.1008).  
2	Under the Court Procedures Act 2004 A2004-59, pt 8, this form became a form approved under that Act.
3	This republication includes amendments made under the Legislation Act, part 11.3 (Editorial changes).

©  Australian Capital Territory 2005