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Prescribed Form 04

Prescribed Form 04 – Written Statement by Participant Challenging a Decision on the Basis of Mistaken Identity in a Match Official Send-Off/Expulsion Report (section 7.3)

  • PLEASE NOTE:
    Unless a Team Official has indicated on the team sheet that a Participant has been mistakenly identified, your challenge will not be accepted
    (see section 7.3(a) and (b))

  • Your Details

  • Match Details

  • For example: National Premier Leagues NSW Men's = 1st Grade
  • Date Format: DD slash MM slash YYYY
  • :

  • Submission

  • 1. I declare that the following Participant of my Club was responsible for the Offence and the Suspension issued against me should be transferred across to the Participant mentioned below:
  • 2. I declare that the information in this statement is accurate and to the best of my knowledge.
  • 3. I acknowledge that I may be charged with Misconduct if it is established that the contents of this statement are incorrect and amount to an abuse of process.

  • Section Break

  • Notes:
  • 1. Please submit this form by 4pm the next working day after the completion of the match.
  • 2. In addition to submitting this form, please submit one of the following forms at the same time:
  • a. Prescribed Form 05 by the Participant actually responsible for the Offence9
  • or
  • Prescribed Form 06 by your Club identifying the Participant responsible for the Offence;
  • and
  • b. Any other evidence which may support your challenge.
  • 3. Participants should read and consider section 7.3 prior to signing and lodging this form to Football NSW.
  • 4. If Football NSW does not receive a properly completed forms by the time specified in Note 1, you are deemed to have committed the Offence and will be issued with a Notice of Suspension.
  • 5. Capitalised words used in this form are defined in the Regulations.

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