Fillable Application To Register A-name Change Under 18 Not Married Civil Union Defacto BDM122 (Department of Internal Affairs New Zealand)

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Application To Register A-name Change Under 18 Not Married Civil Union Defacto BDM122 (Department of Internal Affairs New Zealand)

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Sheet 1 of 11
He tono ki te rēhita i tētahi Panoni Ingoa
Application to register a Name Change
BDM122
Mō tētahi tangata i raro i te 18 tau, kāore anō i mārena, hono ā-ture, moe māori rānei
For person aged under 18 who has not been married, in a civil union or de facto relationship
• For a person whose birth is registered in New Zealand, who is 2 years of age or older but younger than 18 years of age,
and who has never been married, in a civil union or de facto relationship; or
• For a person whose birth is registered outside New Zealand, who is a New Zealand citizen or entitled, under the
Immigration Act 2009, to be in New Zealand indefinitely, who is younger than 18 years of age, and who has never been
married, in a civil union or de facto relationship.
Other name change forms
• Application to register a name change of a person aged
18 or older, or under 18 and is, or has been, married, in a
civil union or de facto relationship (form BDM 120
).
• Request for name change within 2 years of birth (form
BDM 36) for births registered in New Zealand where the
person is under 2 years of age.
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 about the new name
The new name must consist of one surname and one or
more other names, unless your religious or philosophical
beliefs, or cultural traditions require the person 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 the 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 the 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.
Sheet 2 of 11
All legal guardians must sign
The guardians of the person whose name is to be changed should give all the information requested on this form about
themselves and about that person.
If the person whose name is to be changed is aged 16 or 17, that person must sign the panel giving his or her consent to
the name change (that signature does not have to be witnessed).
The child’s father and mother are usually joint
guardians
The father and the mother of a child are guardians jointly
of the child unless the child’s mother is the sole guardian
of the child. If the child is legally adopted by opposite-sex
or same-sex parents, those parents are guardians of the
child through the adoption.
Father as guardian
• The mother and father are both guardians if they jointly
registered the birth of the child on or after 1 July 2005 by
completing and signing the Notification of Birth for
Registration form (BDM27).
• The father is usually a guardian of the child if the father’s
particulars were added to the child’s birth information on
or after 1 July 2005 but no later than 24 January 2009.
Appointment of 1 or more additional guardians
• A testamentary guardian of the child appointed by the
deceased parent under section 26(2) of the Care of
Children Act 2004 or section 7(2) of the Guardianship
Act 1968.
• All Court appointed/approved guardians. A certified copy
of the Court appointment as a guardian should be
attached to this declaration.
A guardian may act alone
• In some circumstances a guardian may act alone if the
other guardian(s) is/are dead, unknown, missing (note
that a guardian is not missing if others know of their
whereabouts but they refuse to tell you), of unsound
mind or unable to act because of a medical condition; or
• If Family Court approval is obtained. Appropriate
evidence must be attached to this declaration (note that
this is not a Parenting or Protection order).
Other parent
If the child was born as a result of an assisted human
reproduction procedure (such as artificial insemination),
and the mother was living in a marriage, civil union or de
facto relationship with a man or a woman who had
consented to her undergoing the procedure, and the
man’s or woman’s name is recorded on the child’s birth
registration, then that man or woman must also sign this
declaration.
The mother is the sole guardian
If a child is conceived before 1 July 2005, the child’s
mother is the sole guardian of the child if the mother was
not:
• Married to, nor in a civil union with, the father of the child
at any time during the period beginning with the
conception of the child and ending with the birth of the
child; and not
• Living with the father of the child as a de facto partner at
the time the child was born.
If a child is conceived on or after 1 July 2005, the child’s
mother is the sole guardian of the child if the mother was
not:
• Married to, nor in a civil union with, the father of the child
at any time during the period beginning with the
conception of the child and ending with the birth of the
child; and not
• Living with the father of the child as a de facto partner at
any time during that period.
If the child is born as a result of an assisted reproduction
procedure (such as donor insemination) to a mother
acting alone, and the donor is not the mother’s partner
(i.e. not in a marriage, civil union or de facto relationship),
and the donor does not become the mother’s partner
between conception and notification of the birth for
registration, then the mother is the sole guardian.
Sheet 3 of 11
Documents to attach
If the birth of the person whose name is to be changed:
• is registered in New Zealand you must provide documents from List 2 and 3.
• is registered overseas you must provide documents from List 1, 2 and 3.
List 1: Eligibility of the person whose name is to be changed to apply to register a name change in NZ
• If the person whose name is to be changed birth is registered in New Zealand go directly to List 2.
• If the person whose name is to be changed birth is registered outside New Zealand they must provide evidence of the date and place of
their birth, and of their status as a NZ citizen or person who is entitled, under the Immigration Act 2009, to be in NZ indefinitely. Provide a
certified true copy of one (or combination if applicable) of the following current documents:
x 1
New Zealand Passport (a certified copy of the page with the photo on it is sufficient) and a Birth Certificate that includes names of
parent(s)
New Zealand Citizenship Certificate and a Birth Certificate that includes name(s) of parent(s)
Australian Passport or some other evidence of Australian citizenship and a Birth Certificate that includes names of parent(s)
Cook Islands, Niue or Tokelau Birth Certificate that includes names of parent(s)
Overseas Passport including a residence permit or resident visa issued by Immigration New Zealand that
includes names of parent(s)
Letter from Immigration New Zealand confirming permanent residence status (if the letter states the person’
name, date of birth, place of birth and names of parent(s)
Overseas Birth Certificate that includes names of parent(s) together with a letter/permit/visa from Immigration
New Zealand confirming permanent residence status
Notarial Certificate (China) that includes names of parent(s) together with a letter/permit/visa from Immigration
New Zealand confirming permanent residence status
Household/Family Census Register that includes names of parent(s) from an Asian country together with a letter/permit/visa from
Immigration New Zealand confirming permanent residence status.
List 2 All guardians must provide current photo identification
All guardians must each provide a certified true copy of one of the following, which includes their photo:
All guardians must also present their current photo identification to the person authorised to take a statutory declaration at the time
that they sign the declaration on page 3 of the form. That person may also be able to certify their 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 All guardians must provide proof of the use of their identity in the community
All guardians must each 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
Sheet 4 of 11
All legal guardians must sign before a person authorised to take a statutory declaration
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
Some 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
Sheet 5 of 11
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
Sheet 6 of 11
BDM122
Remember to include evidence
• Please read the Notes pages of this application form carefully before you start
• If there are more than two guardians continue on separate form
i
1. Old name
Name at birth is (if legally adopted then enter the names given after the adoption)
SurnameAll first and middle names
If the guardians have previously registered a name change for the child in New Zealand or overseas. The name below is the
name changing from, if it is different from the name at birth
Surname of most recently registered name change
All first and middle names of most recently registered name change
2. Date of birth
YearMonthDay
Date of birth
3. Place of birth
Town or City of birth
Country (if not New Zealand)
4. Your contact details, if we have questions about this application
Guardian 1’s full name
Guardian 1’s best phone number
Guardian 1’s email Guardian 2’s email
Guardian 2’s best phone number
Guardian 2’s full name
5. Evidence provided with this application, if applicable
What do you want us to do with the evidence you have attached, if applicable?
Return it to you Destroy it
Only provide certified true copies of your evidence
Last updated: 4 Deember 2019
He tono ki te rēhita i tētahi Panoni Ingoa
Application to register a Name Change
Mō tētahi tangata i raro i te 18 tau, kāore anō i mārena, hono ā-ture, moe māori rānei
For person aged under 18 who has not been married, in a civil union or de facto relationship
4/12/19
Sheet 7 of 11
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
We are acting together to complete this declaration --> Go to question 7
6. If acting alone as a guardian
I, as the child's mother, am the sole guardian because the child
was conceived before 1 July 2005 and I was not married to, nor
in a civil union with, the father of the child at any time during the
period beginning with the conception of the child and ending with
the birth of the child; and I was not living with the father of the child
as a de facto partner at the time the child was born, and none of
the exceptions apply
I, as the child’s mother, am the sole guardian because the child
was conceived on or after 1 July 2005 and I was not married to,
nor in a civil union with, the father of the child at any time during
the period beginning with the conception of the child and ending
with the birth of the child; and I was not living with the father of the
child as a de facto partner at any time during that period, and none
of the exceptions apply
The guardian(s) is/are missing
Exceptions:
• The mother and father jointly registered the birth
on or after 1 July 2005 by completing and signing
the Notification of Birth for Registration form
(BDM27).
• The father’s particulars were included in the
child’s birth information on or after 1 July 2005
but no later than 24 January 2009.
• A testamentary guardian of the child has been
appointed by the deceased parent under section
26(2) of the Care of Children Act 2004 or section
7(2) of the Guardianship Act 1968.
• The Court has appointed any other person(s) a
guardian.
State the recent actions within the last 2 months that you have taken to contact the other guardian(s) and include the date you
tried to contact them. This includes searching the electoral roles, the Internet, asking family and friends or former employers.
You must also state that you and all the people that know the guardian (which you have contacted) have no way of contacting
them:
I/we searched the electoral roles on date (DD/MM/YYYY)
I/we searched the Internet on date (DD/MM/YYYY)
I/we asked family members on date (DD/MM/YYYY)
I/we asked friends on date (DD/MM/YYYY)
I/we asked their employers on date (DD/MM/YYYY)
I/we and all people who known the guardian(s), who I/we have contacted, have no way of contacting the guardian(s)
One or more of the above do not apply - State why:
6. Acting alone as a guardian continues...
Sheet 8 of 11
i All corrections must be initialled, dated by yourself then witnessed by a person authorised to take a statutory declaration
I, as the child’s mother, am the sole guardian because the child was born as a result of an assisted reproduction
procedure (such as donor insemination) to me acting alone, and the donor is not my partner (i.e. not in a marriage, civil union
or de facto relationship), and the donor did not become my partner between conception and notification of the birth for
registration.
The guardian(s) is/are dead - If died in New Zealand, enter the deceased’s name, date of death and place of death.
If died overseas, include a certified true copy (or original) of the deceased’s death certificate:
Deceased's full name
Date of death (DD/MM/YYYY)
Place of death
The Family Court has given consent for me to act alone - Attach a copy of the Family Court order (not a Parenting order,
previously known as a Custody order)
The guardian is unable to act because of a medical condition or they are of unsound mind - Provide evidence from a
Registered Medical Doctor
8. Where is the person’s old name registered? (tick one)
In New Zealand, or
Outside New Zealand
9. The new names are (the new name must comply with the “Guidelines about the new name” in the notes pages at
the start of this application)
Surname of the new name
All first and middle names
10. Are you already using the new name or do you intend to start using it in the future? (tick one)
I/We are already using the new name, or
I/We intend to use the new name in the future
7. Consent, if person whose name is being changed is 16 or 17 years old
I am the person whose name is to be changed and I consent to the name change as set out in this application by my guardian(s)
Signature of person whose name is being changed, if they are 16 or 17 years old
Date signed (DD/MM/YYYY)
Sheet 9 of 11
i All corrections must be initialled, dated by yourself then witnessed by a person authorised to take a statutory declaration
11. Your full name, occupation and residential address
Guardian 1’s First names
Guardian 1’s Surname
Guardian 1’s Occupation Guardian 2’s Occupation
Guardian 2’s Surname
Guardian 2’s First names
Residential address - this is not a PO Box 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)
Flat no Street no Street
Suburb or rural locality
City, town or district Postcode
Country (if not New Zealand)
Sign before a person authorised to take a statutory declaration. Refer notes pages for the list
I/We solemnly and sincerely declare that the information herein in this statutory declaration is accurate and complete and I/we 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 (Guardian 1’s Signature)
this day of (DD/MM/YYYY)
Declared at (Town or city, and country if not New Zealand)
by (Guardian 2’s Signature)
The person authorised to take a statutory declaration
must complete this section
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 3 of
the notes). The document I relied on was:
I am satisfied of the declarant's identity by sighting his or her
original photo identification document (from List 2 on page 3 of
the notes). The document I relied on was:
Document name (e.g. New Zealand Passport)
Document number (e.g. passport number)
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 notes pages for authorised persons)
before me
Signature - authorised person signs here
Qualification of authorised person
(Refer notes pages for authorised persons)
Copy Guardian
1's address
Sheet 10 of 11
12. Fees and Payment details
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 >>>
Application fee to register a name change
If a certificate is required to show the new name:
I choose the following method to pay for the order:
Do not post cash
VISA Mastercard AMEX
Prezzy Card
Card Number
Expiry Date
Cardholder's name Cardholder's signature
Don't post us
your card
Delivery Address, if ordering a certificate
Flat no Street no Street
Suburb or rural locality
City, town or district Postcode
Country (if not New Zealand)
Guardian 1's address Guardian 2's address
Copy:
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.
First name(s) Surname
>> Select country from list<<
$170.00
Sheet 11 of 11
13. Human Assisted Reproductive Technology (HART) Register
HART Register (optional) - 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
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Application To Register A-name Change Under 18 Not Married Civil Union Defacto BDM122 (Department of Internal Affairs New Zealand)

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Completed 16 July 2020

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