FORM 81A-X
rule 81A.41(17)
File No: [file number]
ORDER UNDER SECTION 19B OF
CRIMES ACT 1914 OF THE COMMONWEALTH
To: [Offender's full name]
of [address] 
On [date] the Supreme Court found the following charge(s) proven against you:
CASE & OFFENCE NOS	
OFFENCE	
File number	[No]	[offence]	

and ordered that:
(a)	the charge be dismissed; 
OR
(b)	the offender be discharged, without proceeding to conviction, upon [his/her] giving security by [recognisance / [state other]], [without a surety / with a surety of $[amount of surety]], that [he/she] will comply with the following conditions:
(i)	that the offender will be of good behaviour for [period of order] years;
(ii)	that the offender will:
(A)	make reparation or restitution in respect of [item and amount];
(B)	pay compensation of $[amount]; 
(C)	pay costs of $[amount],
by [date/s of payment]; 
(iii)	[any other orders].
This order starts on [date] and ends on [date].
Date: [date]
JUDGE