(Full name)
do solemnly and sincerely declare that:
I acknowledge that this declaration is true and correct and I make it in the belief that a person
making a false declaration is liable to the penalties of perjury.
Declared at
in the State of Victoria
this day of 20
(Signature of person making declaration)
Before me:
(Signature of authorised witness)
(The witness must print their name, address and
their authority under section 107A of the Evidence
(Miscellaneous Provisions)Act 1958 to witness a
statutory declaration