Fillable Application To Register A-name Change BDM120 (Department of Internal Affairs New Zealand)

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Application To Register A-name Change BDM120 (Department of Internal Affairs New Zealand)

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Country of origin: NEW-ZEALAND
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Page 1 of 9
He tono ki te rēhita i tētahi Panoni Ingoa
Application to register a Name Change
BDM120
Mō tētahi tangata 18 tau, neke atu rānei, kei raro rānei i te 18 tau, i mārena, hono ā-ture, moe māori rānei.
For a person: aged 18 or older; or under 18 and are, or have been, married, in a civil union or de facto
relationship.
Who can register a name change?
To register a name change in New Zealand on or after 25
January 2009:
• Your birth must be registered in New Zealand; or
• If your birth is registered outside New Zealand, you must
be a New Zealand citizen or entitled, under the
Immigration Act 2009, to be in New Zealand indefinitely
(e.g. as a permanent resident).
You must make true statements
You must make true statements when completing this
application. If you make, or cause to be made, any false
statement or declaration you will be liable, on conviction, to
a fine or up to 5 years imprisonment, or both.
How long will it take?
Applications will be processed in 15 working days, from
receiving a correct and complete application (plus postage
time). If you have requested a certificate showing your new
name, it will be issued as soon as the name change is
processed.
Guidelines for the new name
Your new name must consist of one surname and one or
more other names, unless your religious or philosophical
beliefs, or cultural traditions require you to bear only one
name - in which case attach a letter of explanation.
What is not acceptable?
The new name (or combination of names) may not be
accepted for registration if:
• it might cause offence to a reasonable person; or
• it is unreasonably long (that is, it should be less than 100
characters long, including spaces); or
• without adequate justification, it is, includes, or resembles,
an official title or rank (in which case attach a letter of
explanation); or
• it is not a name (for example, it must not include numbers
or symbols).
Certificate showing the new name
Birth registered in New Zealand
Birth registered outside New Zealand
If your birth is registered in NZ, any new
birth certificate that is issued will show the
new name as well as all previous names.
A new birth certificate can be made
available after registration, on payment of
an additional fee.
If your birth is registered outside NZ, any
new name change certificate that is
issued will show the new name as well as
all previous names registered in NZ on or
after 25 January 2009. A new name
change certificate can be made available
after registration, on payment of an
additional fee.
Complete on-screen and print
You can complete this form on-screen using the Editable PDF functionality with Adobe Reader.
You must still print off the application and have signed where applicable by hand.
If you are unsure whether to order a certificate, you
should check with any organisations that you intend to
advise of your name change about their requirements.
Page 2 of 9
Documents to attach
If your birth is registered in New Zealand you must provide documents from List 2 and 3.
If your birth is registered overseas you must provide documents from List 1, 2 and 3.
List 1: Your eligibility to apply to register a name change in NZ
• If your birth is registered in New Zealand go directly to List 2 (as you are eligible to apply to register a name change).
• If your birth is registered outside New Zealand you must provide evidence of the date and place of your birth, and of your status as a
New Zealand citizen or person who is entitled, under the Immigration Act 2009, to be in New Zealand indefinitely. Provide a certified true
copy of one (or combination if applicable) of the following current documents:
x 1
New Zealand Citizenship Certificate
New Zealand Passport (a certified copy of the page with your photo on it is sufficient)
New Zealand Certificate of Identity issued under the Passports Act 1992 with a letter/permit/visa from
Immigration New Zealand confirming permanent residence status
Australian Passport or some other evidence of Australian citizenship
Cook Islands, Niue or Tokelau Birth Certificate
Overseas Passport including a residence permit or resident visa issued by Immigration New Zealand
Letter from Immigration New Zealand confirming permanent residence status (if the letter states your
name, date and place of birth)
Overseas Birth Certificate together with a letter/permit/visa from Immigration New Zealand confirming
permanent residence status
Notarial Certificate (China) together with a letter/permit/visa from Immigration New Zealand confirming
permanent residence status
Household / Family Census Register from an Asian country together with a letter/permit/visa from
Immigration New Zealand confirming permanent residence status.
List 2 Your current photo identification
You must provide a certified true copy of one of the following, which includes your photo (If you are providing a document from List 1 that has
your photo on it go directly to List 3):
You must also present your current photo identification to the person authorised to take a statutory declaration at the time
that you sign the declaration. That person may also be able to certify your documents at the same time.
Include an official English translation of any
document that is not in the English language
x 1
New Zealand or overseas Passport (a certified copy of the page with your photo on it is sufficient)
New Zealand or International Driver Licence
New Zealand or overseas Firearms or Dealer’s Licence
New Zealand or overseas Defence force or police service photo identity card
New Zealand Emergency Travel Document
New Zealand Certificate of Identity (issued under the Passports Act 1992)
New Zealand Certificate of Identity (issued under the Immigration Act 2009)
New Zealand Refugee Travel Document
Overseas identity card
18+ Card or Kiwi Access Card (issued by Hospitality New Zealand) or overseas proof of age card
Contact us if you cannot meet these requirements
List 3 Proof of the use of your identity in the community
You must provide copies of two documents from different sources, for example:
x 2
Rates notices
Electoral Roll Record
Motor vehicle registration
Student or tertiary identity card
Educational certificate or school report
Trade certificate
Steps to Freedom form
Certificate of approval or licence issued by the Private Security Personnel
Licensing Authority
Confirmation of Permit Status from Immigration
Inland Revenue Tax Number (provide an IR card or statement)
Lease or tenancy agreements
Bank statements (including savings, credit or cheque accounts)
Utility accounts (including gas, water, electricity, mobile or home phone)
document,
if birth not
registered in NZ
document
documents
Community Services Card
Page 3 of 9
You must sign before one of these people
The qualification of the person authorised to take a statutory declaration must be one of the following and depends on whether you are
making the declaration in New Zealand, or outside New Zealand and in a Commonwealth country. If outside New Zealand and you are
not sure if the country is a Commonwealth country refer to the list of member states at www.thecommonwealth.org
In New Zealand
Commonwealth country
other than New Zealand
A country other than a
Commonwealth country
Any other person authorised by law to
administer an oath
Registrar or a Deputy Registrar of the
Supreme Court, Court of Appeal, High
Court or a District Court
Person enrolled as a barrister and
solicitor of the High Court
Justice of the Peace
Registrar of Births, Deaths and Marriages Commonwealth representative
Justice of the Peace
Notary Public
Judge
Commissioner of Oaths
Solicitor of the High Court of
New Zealand
A person authorised by the law of that
country to administer an oath for the
purpose of a judicial proceeding. Refer
below for examples:
Solicitor of the High Court of
New Zealand
Notary Public
Judge
Commonwealth representative
All of Australia
• Judge
• Notary Public
• Justice of the Peace
• Solicitor of the High Court of New Zealand
• Australian legal practitioner
• Court clerk or registrar who certifies his or her
authority to take an oath for a judicial proceeding
• Commonwealth Representative
Also, if in South Australia
• Commissioner for Affidavits
Also, if in Western Australia
• A mining registrar appointed under the Mining Act
1978
• Australian Police are not authorised to take this statutory
declaration, unless you are in the Northern Territory.
• Australian Pharmacists, Optometrists and Doctors are not
authorised to take this statutory declaration.
Also, if in Northern Territory
• Commissioner for Oaths (by personal appointment)
• Member of the Legislative Assembly
• Member of house of the Parliament of the
Commonwealth elected to represent the Territory or a
constituency in the Territory
• Member of the Police Force who has attained the age
of 18 years
Also, if in Queensland
• Commissioner for Declarations
• Conveyancer
England or Wales
• Judge
• Commissioner of Oaths (by personal appointment)
• Notary Public
• Justice of the Peace
• Solicitor of the High Court of New Zealand
• Solicitor
• Barrister
• Legal Executive
• Licensed Conveyancer
• Court clerk or registrar who certifies his or her
authority to take an oath for a judicial proceeding
• Commonwealth representative
Ireland or Northern Ireland
• Judge
• Solicitor
• Notary Public
• Justice of the Peace
• Court clerk or registrar who certifies his or her
authority to take an oath for a judicial proceeding
• Commonwealth representative
• Solicitor of the High Court of New Zealand
Scotland
• Judge
• Notary Public
• Justice of the Peace
• Person authorised by the law of that country to
administer an oath for the purpose of a judicial
proceeding
• Commonwealth representative
• Solicitor of the High Court of New Zealand
Page 4 of 9
Post the form, appropriate fee(s), and evidence as applicable, to one of:
New Zealand Sydney London
Name Change Team
Births, Deaths and Marriages
Department of Internal Affairs
PO Box 10-526
Wellington 6143
New Zealand
Births, Deaths and Marriages
Department of Internal Affairs
GPO Box 365
Sydney
New South Wales 2001
Australia
Births, Deaths and Marriages
Department of Internal Affairs
New Zealand House
80 Haymarket
London SW1Y 4TQ
United Kingdom
Privacy Statement
The information provided on this form is collected under the Births, Deaths, Marriages, and Relationships Registration Act 1995
(the “BDMRR Act). A person who makes, or causes to be made, a false declaration on this form will be liable on conviction to a
fine or term of imprisonment, or both. The information will be held on a public register, and may generally be accessed by any
person on application (e.g. as a certificate or printout). The Births, Deaths, Marriages, Citizenship, Authentications and
Translations office may also release it to certain government agencies and foreign registration authorities, as authorised by law.
The BDMRR Act governs access to registered information. Information about your rights to access and, where appropriate, correct
the information is available on our website www.govt.nz/bdm or Freephone 0800 22 52 52.
Contact Details
Births, Deaths, Marriages, Citizenship, Authentications and Translations:
• Website www.govt.nz/bdm
• Freephone 0800 22 52 52 (New Zealand only). If overseas phone (+64 9) 339 0852
• Email bdm.nz@dia.govt.nz
Page 5 of 9
BDM120
Remember to include evidence
• Please read the Notes pages of this application form carefully before you start
• You may experience delays or your application may be unsuccessful if it is not correct and complete
i
1. My old name
My name at birth is (if legally adopted enter the names you were given after the adoption)
SurnameAll first and middle names
My name if I have previously registered a name change. (The name you are changing from if it is different from your name at
birth. The name is not a surname assumed on marriage or civil union, even if that surname was included on your passport)
Surname of my most recently registered name change
All first and middle names of my most recently registered name change
2. My date of birth
YearMonthDay
Date of my birth
3. My place of birth
Town or City of birth
Country (if not New Zealand)
4. My contact details
Best phone number Email
5. I want the original evidence I provide with this application:
Return it to me
Securely destroyed
Only provide certified true copies of original evidence
Current Date
Last updated: 16 October 2019
Refer to page 2:
My birth is registered in NZ so I have attached
documents from List 2 and 3.
My birth is registered outside NZ so I have attached
documents from List 1, 2 and 3.
He tono ki te rēhita i tētahi Panoni Ingoa
Application to register a Name Change
Mō tētahi tangata 18 tau, neke atu rānei, kei raro rānei i te 18 tau, i mārena, hono ā-ture, moe māori rānei.
For a person: aged 18 or older; or under 18 and are, or have been, married, in a civil union or de facto
relationship.
16/10/19
Page 6 of 9
Statutory Declaration
• I authorise any necessary additional enquiries including the disclosure of personal information about myself and the person
whose name is being changed for the purpose of determining eligibility for this name change application. My authorisation
includes any information held by the Department of Internal Affairs or another NZ government agency.
• If I submit an application for New Zealand citizenship or a New Zealand passport at the same time as this application is
submitted, I authorise any necessary additional enquiries including the disclosure of personal information about myself and the
person whose name is being changed so both applications can be processed.
Take care completing this statutory declaration as you may be required to do it again if there are errors.
i
solemnly and sincerely declare that:
Married or in a civil union?
Assumed surname
Generally, you do not need to register your assumed surname on marriage or civil union as organisations
may acknowledge your new surname using some other evidence, such as your marriage certificate.
Only changing your first names
If you are married or in a civil union and only want to change your first names, enter the surname of your
new name as it is currently recorded on your birth registration (do not print a surname you assumed on
marriage).
i
6. I (enter your current full name)
My current full name
7. of (enter your residential address. This is not a PO Box)
Flat no Street no Street
Suburb or rural locality
City, town or district Postcode
Country (if not New Zealand)
8. a (enter your occupation. If no occupation enter ‘no occupation’)
My occupation
9. If 16 or 17 years of age, I am or have been in a:
Marriage
Civil Union
De facto relationship
Date of marriage/civil union Place of marriage/civil union
g
g
Page 7 of 9
i All corrections must be initialled, dated by yourself then witnessed by a person authorised to take a statutory declaration
10. My old legal name was formally registered in: (tick one)
New Zealand
Outside New Zealand
12. I advise that: (tick one)
I am already using my new name, or
I intend to use my new name in the future
11. My new name is (refer to the “Guidelines for the new name” on page 1):
Surname
All first and middle names
Sign before a person authorised to take a statutory declaration. Refer to page 3 for the list
And I make this solemn declaration conscientiously believing the same to be true and by virtue of the Oaths and Declarations Act
1957.
this day of (DD/MM/YYYY)
Declared at (Town or city, and country if not New Zealand)
by (Signature of declarant)
The person authorised to take a statutory declaration must complete this section
I am satisfied of the declarant's identity by sighting his or her original photo identification document (from List 2 on page 2).
The document I relied on was:
Document name (e.g. New Zealand Passport) Document number (e.g. passport number)
before me
Signature - authorised person signs here
Qualification of authorised person (refer to page 3 for authorised persons)
Full name of authorised person
Page 8 of 9
13. Fees and Payment details
Application fee to register a name change
If a certificate is required to show your new name:
Standard
and Forest
Standard
and Beach
Forest Beach Standard
For a limited time only:
'All Blacks'
NZ Birth Certificate
Name Change
Certificate
Only if the birth
is registered
overseas
Two certificate
package
$55.00
Enter quantity
below
Two certificate
package
$55.00
Enter quantity
below
$35.00 each
Enter quantity
below
$35.00 each
Enter quantity
below
$33.00 each
Enter quantity
below
Standard and
All Blacks package
$55.00
Enter quantity
below
$35.00 each
Enter quantity
below
$33.00 each
Enter quantity
below
Courier fee
(optional)
To a New Zealand address $5
In list below number in brackets is
estimated delivery in working days
To an overseas address >>>
I have enclosed a New Zealand cheque or International bank draft in NZ dollars made out to the Department of Internal Affairs.
Note: Australian money orders can only be receipted at the Sydney office.
Charge my credit card
I choose the following method to pay for the order:
VISA Mastercard AMEX
Card Number
Expiry Date
Cardholder's name Cardholder's signature
Delivery Address, if ordering a certificate (if to a different address amend pre-entered details)
Delivery name
Flat no Street no Street
Suburb or rural locality
City, town or district Postcode
Pictorial certificates will be posted flat in an A4 size reinforced
envelope. Standard certificates will be folded into a standard DLE
envelope with address details printed on the back of the certificate.
Country (if not New Zealand)
$170.00
>> Select country from list<<
Page 9 of 9
15. Human Assisted Reproductive Technology (HART) Register
Only complete and return this page if it is applicable
This section only applies if the person whose name is being changed was born as a result of an assisted reproductive
technology procedure using donated sperm, eggs or embryos through a fertility clinic. If information has been provided to Births,
Deaths and Marriages for inclusion on the HART Register, it will be updated to include the person’s new name. This means that
up-to-date information will be provided to persons who are authorised to access your information under the Human Assisted
Reproductive Technology Act 2004.
Are you a donor or person born as a result of a HART procedure?
Yes, the person whose name is being changed was born as a result of a HART procedure whose details are recorded on
the HART Register
If the birth occurred as a result of a donation made after 21 August 2005, information will also be held by the fertility clinic. We can
send information about the name change to the fertility clinic, so that the clinic’s records can be updated.
Consent for new name to be sent to clinic
Yes. I consent to the new name being sent to the fertility clinic named below that holds the information
Fertility clinic name
14. Including your new names on your New Zealand marriage or civil union record
The first few pages of this application are to register a name change on your birth record (if registered in New Zealand) or name
change record (if your birth is registered overseas). Once registered, you may order a certificate as evidence of your new name -
usually this is all you need to do.
For an extra fee of $55.00 (plus an optional $33.00 for a marriage/civil union certificate), and if you are currently married or in a
civil union and your marriage or civil union is registered in New Zealand, you may, if you wish, choose to have your new names
added to your marriage or civil union record.
I have included the additional fee of $55.00 and request that my new name be recorded on my
New Zealand registered marriage or civil union
I have included an additional $33.00 for a marriage or civil union certificate to be issued after my
new name is recorded on my New Zealand registered marriage or civil union
$
$
Answer for your most recent New Zealand marriage or civil union
Marriage
Civil Union
Date of marriage/civil union (DD/MM/YYYY)
Place of marriage/civil union in New Zealand
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Application To Register A-name Change BDM120 (Department of Internal Affairs New Zealand)

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Completed 16 July 2020

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