Statutory Declaration
I (Enter your full name)
of (Enter the address where you live)
(Enter your occupation – for example, bricklayer, teacher, unemployed)
solemnly and sincerely declare that
(List the facts in your own words. Number each point to make it clearer)
Note: What you write must be true. You can be prosecuted if you make a false declaration.
I make this solemn declaration conscientiously believing the same to be true and by virtue of the Oaths and
Declarations Act 1957.
Note: Do not complete the following section until you are with the person witnessing your declaration.
Your signature
Declared at (Place, for example town or city)
Before me (Name of official witness)
(For example, a Justice of the
Peace, solicitor or another person
authorised to take a statutory
Signature of official witness