Fillable Form 1: STATUTORY DECLARATION Statutory Declarations ACT 1959 (Department of Infrastructure, Transport, Cities and Regional Development)

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Form 1: STATUTORY DECLARATION Statutory Declarations ACT 1959 (Department of Infrastructure, Transport, Cities and Regional Development)

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Commonwealth of Australia
STATUTORY DECLARATION
Statutory Declarations ACT 1959
92, 015 (03/2014)
1
name
Insert the name,
address and
occupation of
person making
the declaration
Set out matter
declared to in
numbered
paragraphs
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.
2 2
address
occupation
I,
make the following declaration to the Road Transport Authority under the Statutory
Declarations Act 1959:
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.
STOP you must print this statutory declaration and sign it in front of a person mentioned over the page.
1
Signature of
person making
the declaration
3 3
Signature of
person before
whom the
declaration is
made (see over)
7 7
Before me,
4
Place
Day
Month and year
4
5
6
Declared at on of
5 6
Full name,
qualication
and address of
person before
whom the
declaration is
made (in printed
letters)
8 8
full name
month, yearplace
day
qualication
address
PRINT
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 ofce supplying postal services to the public
Australian Consular Ofcer or Australian Diplomatic Ofcer (within the meaning of the Consular Fees Act 1955)
Bailiff
Bank ofcer with 5 or more continuous years of service
Building society ofcer with 5 or more years of continuous service
Chief executive ofcer of a Commonwealth court
Clerk of a court
Commissioner for Afdavits
Commissioner for Declarations
Credit union ofcer 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 ofcer with 5 or more years of continuous service
Holder of a statutory ofce not specied 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 ofcer; or
(b) a non-commissioned ofcer within the meaning of the Defence Force Discipline Act 1982 with 5 or more years of continuous service; or
(c) a warrant ofcer within the meaning of that Act
Member of the Institute of Chartered Accountants in Australia, the Australian Society of Certied 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 ofce 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 specied 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 ofcer
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 ofcer
Teacher employed on a full-time basis at a school or tertiary education institution
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Form 1: STATUTORY DECLARATION Statutory Declarations ACT 1959 (Department of Infrastructure, Transport, Cities and Regional Development)

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Completed 1 December 2020

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