FORM 81A-R
rule 81A.41(11)
IJIS ID: [IJIS ID]						               File No: [file number]
WARRANT OF COMMITMENT FOR NON-PAYMENT OF FINE ETC.
TO THE COMMISSIONER OF POLICE AND ALL MEMBERS OF THE NORTHERN TERRITORY POLICE FORCE AND TO THE OFFICER IN CHARGE OR SUPERINTENDENT OF EACH GAOL, PRISON OR DETENTION CENTRE IN THE TERRITORY
[Offender's full name], [male / female / other], [date of birth]
of c/– [Darwin Correctional Centre / Alice Springs Correctional Centre / Holtze Youth Detention Centre / Don Dale Youth Detention Centre / Other ] AT [Darwin / Alice Springs] in the Northern Territory

was found guilty by this Honourable Supreme Court of the Northern Territory at [Darwin / Alice Springs] of the following offences and on [date] it made orders for the payment of fines, costs etc. for them. The defendant has not paid the total amount owing in respect of those orders. The amounts owing are shown below:
CASE & OFFENCE NOS	
OFFENCE	
BALANCE OWING FOR	
	FINE	COSTS	LEVY	TOTAL	DAYS IN DEFAULT	
File number
	[No]	[offence]	$	$	$	$
	[number] days 	
								
TOTALS	Warrant Fee	$		
	AMOUNT	$	[number] days to be served cumulatively with the sentence imposed on [date]	

YOU the said Members are ordered to arrest and convey the defendant to the nearest [where applicable: gaol/ prison/ detention centre] and deliver the defendant to the officer in charge or superintendent there.
The officer in charge or superintendent there must receive the defendant into that officer’s custody and keep the defendant for the total default period, unless the total of this warrant is sooner paid.
Date: [date]
JUDGE

ENDORSEMENT OF PAYMENTS BY PERSON HAVING
CUSTODY OF THE DEFENDANT
Date of payment: [date]
Amount received: $[amount]
Receipt number: [receipt number]
Signature: