Prescribed Form 04

Written Statement By Participant Challenging
A Decision On The Basis Of Mistaken Identity
In A Match Official Send-Off Report (Section 7.3)
Prescribed Form 04

Your Details

Full Name*

First NameLast Name

FFA Number*

Club Name*

Match Details

Opposition Team*

League*

Grade*

Date & Kick off time*

DayMonthYearHourMinutesAM/PM Option

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:

Offender's Name*

First NameLast Name

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 the Disciplinary Committee.

4. If the CDSFA 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.

Submitter Details

Your name*

First NameLast Name

Your E-mail*

Digital Signature*

I certify that the information entered above is true and correct and was entered by myself.

Submission Date*

DayMonthYear