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 DetailsFull Name* First Last FFA Number*Club Name*Match DetailsOpposition Team*League*National Premier Leagues NSW Men'sNational Premier Leagues 2 NSW Men'sNational Premier Leagues 3 NSW Men'sNational Premier Leagues NSW YouthNational Premier Leagues NSW Youth 2Men's State LeagueNational Premier Leagues NSW Women'sNational Premier Leagues 2 NSW Women'sSkills Acquisition Program (SAP)Regional ConferenceFutsal Premier LeaguesFutsal Premier Leagues 2AWD FutsalAWD Futsal 2Waratah CupState TitlesState CupChampions of ChampionsCountry CupTrial MatchFFA CupAssociation Youth LeagueGirls Conference LeagueOtherIf other, please specify*Grade of the League*For example: National Premier Leagues NSW Men's = 1st GradeDate of Fixture* Date Format: DD slash MM slash YYYY Time of Fixture* : HH MM AM PM Submission1. I declare that the following Participant of my Club was responsible for the Offence:Offender's Name* First Last 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.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 Offence; 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.Your Name* First Last Your E-mail* Digital Signature*I certify that the information entered above is true and correct and was entered by myself Δ