Commonwealth of Australia
STATUTORY DECLARATION
Statutory Declarations Act 1959
1 Insert the name, I,1 HERE: Write your FULL legal name (as it appears on your ID)
address and
occupation of
person making HERE: Write your residential address (where you live)
the declaration
make the following declaration under the Statutory Declarations Act 1959:
2 Set out matter 2
declared to in
numbered
paragraphs
1. I declare that (place a tick or cross in the appropriate box):
Tick This Box If: Since the age of 16 - you HAVE been a permanent resident of a country other than Australia (i.e. you have lived overseas)
since turning 16 years of age, I have been a citizen or permanent resident of a
country/countries other than Australia.
Tick This Box If: Since the age of 16 - you HAVE NOT been a permanent resident of another country (i.e. you have only lived in Australia)
since turning 16 years of age, I have never been a citizen or permanent resident of a
country/countries other than Australia.
* Please only tick ONE of the above options as it applies to you
2. I declare that I have never been:
(a) convicted of murder or sexual assault; or
(b) convicted of, and sentenced to imprisonment for, any other form of assault.
I understand that a person who intentionally makes a false statement in a statutory declaration is
guilty of an offence under section 11 of the Statutory Declarations Act 1959, and I believe that the
statements in this declaration are true in every particular.
3 Signature of 3 Sign here if you agree to the declaration above (Point 2.)
person making
the declaration
4 Place Day (i.e. 5th day) The Month, Year (i.e. May 2021)
5 Day Declared at 4 Suburb: on 5 of 6 The month and year when
day of the month
6 Month and year Where you are when signing this
when you are signing you are signing this form
form
Before me, this form
7 Signature of 7 Signature of the witness, who is authorised to witness you completing this form
person before
whom the
declaration is PLEASE SEE OVER for a full list of of professions who can witness you signing
made (see over) (i.e. Nurse, Doctor, Dentist, Justice of the Peace, Police Officer)
8 Full name, 8
qualification and Full Name, Profession/Qualification and address (BLOCK LETTERS) of the
address of person person approved for witnessing you signing this form.
before whom the
declaration is
made (in printed
letters)
Note 1 A person who intentionally makes a false statement in a statutory declaration is guilty of an offence, the punishment for
which is imprisonment for a term of 4 years — see section 11 of the Statutory Declarations Act 1959.
Note 2 Chapter 2 of the Criminal Code applies to all offences against the Statutory Declarations Act 1959 — see section 5A of
the Statutory Declarations Act 1959.
A statutory declaration under the Statutory Declarations Act 1959 may be made before–
(1) a person who is currently licensed or registered under a law to practise in one of the following occupations:
Chiropractor Dentist Legal practitioner
Medical practitioner Nurse Optometrist
Patent attorney Pharmacist Physiotherapist
Psychologist Trade marks attorney Veterinary surgeon
(2) a person who is enrolled on the roll of the Supreme Court of a State or Territory, or the High Court of Australia, as a legal practitioner (however described); or
(3) a person who is in the following list:
Agent of the Australian Postal Corporation who is in charge of an office supplying postal services to the public
Australian Consular Officer or Australian Diplomatic Officer (within the meaning of the Consular Fees Act 1955)
Bailiff
Bank officer with 5 or more continuous years of service
Building society officer with 5 or more years of continuous service
Chief executive officer of a Commonwealth court
Clerk of a court
Commissioner for Affidavits
Commissioner for Declarations
Credit union officer with 5 or more years of continuous service
Employee of the Australian Trade Commission who is:
(a) in a country or place outside Australia; and
(b) authorised under paragraph 3 (d) of the Consular Fees Act 1955; and
(c) exercising his or her function in that place
Employee of the Commonwealth who is:
(a) in a country or place outside Australia; and
(b) authorised under paragraph 3 (c) of the Consular Fees Act 1955; and
(c) exercising his or her function in that place
Fellow of the National Tax Accountants’ Association
Finance company officer with 5 or more years of continuous service
Holder of a statutory office not specified in another item in this list
Judge of a court
Justice of the Peace
Magistrate
Marriage celebrant registered under Subdivision C of Division 1 of Part IV of the Marriage Act 1961
Master of a court
Member of Chartered Secretaries Australia
Member of Engineers Australia, other than at the grade of student
Member of the Association of Taxation and Management Accountants
Member of the Australasian Institute of Mining and Metallurgy
Member of the Australian Defence Force who is:
(a) an officer; or
(b) a non-commissioned officer within the meaning of the Defence Force Discipline Act 1982 with 5 or more years of continuous service; or
(c) a warrant officer within the meaning of that Act
Member of the Institute of Chartered Accountants in Australia, the Australian Society of Certified Practising Accountants or the National Institute of
Accountants
Member of:
(a) the Parliament of the Commonwealth; or
(b) the Parliament of a State; or
(c) a Territory legislature; or
(d) a local government authority of a State or Territory
Minister of religion registered under Subdivision A of Division 1 of Part IV of the Marriage Act 1961
Notary public
Permanent employee of the Australian Postal Corporation with 5 or more years of continuous service who is employed in an office supplying postal
services to the public
Permanent employee of:
(a) the Commonwealth or a Commonwealth authority; or
(b) a State or Territory or a State or Territory authority; or
(c) a local government authority;
with 5 or more years of continuous service who is not specified in another item in this list
Person before whom a statutory declaration may be made under the law of the State or Territory in which the declaration is made
Police officer
Registrar, or Deputy Registrar, of a court
Senior Executive Service employee of:
(a) the Commonwealth or a Commonwealth authority; or
(b) a State or Territory or a State or Territory authority
Sheriff
Sheriff’s officer
Teacher employed on a full-time basis at a school or tertiary education institution