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.
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