[barcode]
ID: [elector ID]

[elector name]
[elector address]

Dear [elector salutation][elector surname]
Apparent failure to vote – ACT Legislative Assembly election [election date] 

According to my records, it appears that you did not vote at the ACT Legislative Assembly election held on [election date].

It is an offence under the Electoral Act 1992 to fail to vote at an ACT election without a valid and sufficient reason.

Please follow the instructions on the back of this notice to resolve this matter, if you:
•	DID VOTE; or
•	DID NOT VOTE, but believe you have a valid and sufficient reason for not voting; or
•	DID NOT VOTE, and wish to pay the [prescribed penalty - Electoral Act 1992 s161(2)] penalty to finalise the matter.
The penalty for failing to vote is [prescribed penalty - Electoral Act 1992 s161(2)] if paid to the ACT Electoral Commission, or a maximum fine of [0.5 penalty units - Electoral Act 1992 s129(1)] (plus any court costs) if the matter is dealt with by the Court.
If you do not respond to this notice by [reply date], I may be obliged to have the matter dealt with by the Court.
If the elector to whom this notice is addressed is absent or incapacitated, another person may respond on his or her behalf.
Please note that giving false or misleading information in replying to this notice is a serious offence.
Yours sincerely

[Electoral Commissioner name]
Electoral Commissioner
[mailing date]

Elector’s reply regarding apparent failure to vote at the
ACT Legislative Assembly election held on [election date] 
Your enrolment as at polling day was:	[elector name]
[elector enrolled address]	Elector ID:
[elector ID]	
Your daytime
contact phone:		Please PRINT your email
address:		
To reply to this notice:
•	If you are paying the [prescribed penalty - Electoral Act 1992 s161(2)] penalty, use one of the payment methods listed below, or;
•	Provide a reason for not voting, or if you did vote, tell us where you voted, by:
•	Completing the form at www.elections.act.gov.au/failure_to_vote; or
•	Completing and returning this form in the reply-paid envelope provided or scanning and emailing this form to elections@act.gov.au.
Please note – information about where you voted or why you did not vote cannot be taken over the phone.
1.  IF YOU DID VOTE
Write the name of the polling place where you voted for the ACT Legislative Assembly election on [election date]:		
2.  IF YOU DID NOT VOTE and believe you have a valid and sufficient reason for not voting
Please state your reason below.  You will be advised if your reason is not acceptable.
I did not vote at the ACT Legislative Assembly election held on [election date] because	

	
3.  IF YOU DID NOT VOTE and wish to pay the penalty of [prescribed fine - Electoral Act 1992 s161(2)]
Do not send cash through the postal service.

Please use one of the payment methods below:
Internet		Pay by credit card (Mastercard, Visa) or debit card over the internet at www.elections.act.gov.au/failure_to_vote (do not return this form).
Phone		Pay by credit card (Mastercard, Visa) or debit card over the phone, by contacting the Access Canberra Contact Centre on [phone number] between:
Elector ID:
[elector ID]

[barcode]	

	
	
•	Monday to Friday – [time range – am to pm] 
•	Saturday - [time range – am to pm]
•	Sunday - [time range – am to pm].  
Your payment details will be processed via the internet (do not return this form).
Elections ACT Office  
Pay by cash, or cheque/money order, made out to the ACT Electoral Commission, or by credit card (Mastercard or Visa) or debit card, at the office of Elections ACT, Monday to Friday – 9:00am to 5:00pm – bring this form with you.  Your payment details will be processed via the internet if paying by credit or debit card. 

Address: [address details]

Note:  Payment of the [prescribed penalty - Electoral Act 1992 s161(2)] penalty fully discharges any liability in relation to your apparent failure to vote.  No further proceedings can be taken against you and you will not be regarded as having been convicted of an offence.  However, if for any reason your cheque is not honoured by your bank, or the credit or debit card details provided are rejected, it will be deemed that payment of the penalty has not been made.