Fillable change of namechange of name Application to register (Services Australia)

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change of namechange of name Application to register (Services Australia)

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Services Australia, (previously DHS - Department of Human Services) is responsible for delivering services relating to health and welfare of Australian citizens. It processes payment of child support other services.

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Application to register a Application to register a
change
of namechange of name
(adult 18 years or over)
BDM400-C|JULY21
1
BDM400-C
'ĞŶĞƌĂů/ŶĨŽƌŵĂƟŽŶ
Eligibility
• You must be 18 years of age or older;
• You must be born or your birth must be registered
in Western Australia (WA); or
• If born overseas, you must be an Australian citizen
or permanent resident AND have continuously
lived in WA for twelve consecutive months before
the date of your application.
Born Interstate
You must apply to the Registry in the State or Territory
of your birth.
MƵůƟƉůĞŶĂŵĞĐŚĂŶŐĞƐ
You can only change your name by registration in
Australia ŽŶĐĞ in any twelve (12) month period.
ŚĂŶŐĞŽĨŶĂŵĞďLJŵĂƌƌŝĂŐĞ
If married in Australia you can assume your spouse’s
name by marriage through common usage and
registration is not usually necessary.
The Registry is not able to advise you whether you
are required to register a change of name if you
choose to assume your spouse’s name, were married
overseas or wish to revert to your maiden name.
You must check whether you need to register a
change of name in these circumstances with the
organisation(s) requesting evidence of your name
before applying as they will determine what is
acceptable to confirm your name.
^ƵĐĐĞƐƐĨƵůĂƉƉůŝĐĂƟŽŶƐ
If your application is successful:
• If you are born in WA your birth certificate will
record the new name at the bottom of the
certificate. This notation will appear on all birth
certificates issued after the change of name is
registered. Your original birth name will still be
recorded on your birth certificate. A separate fee is
payable for a replacement birth certificate.
*See page 11
• Name changes may be notified to other
organisations, such as the Police Department,
Corrective Services, Passport Office, Department of
Home Affairs and Department of Transport etc.
ĂŶŵLJĐŚĂŶŐĞŽĨŶĂŵĞďĞƌĞĨƵƐĞĚ͍
The Registrar may refuse your application if:
1. You are unable to produce the required proof of
identity documents.
2. If you have registered a change of name within
the last twelve (12) months anywhere in Australia.
3. You have failed to declare all previous changes of
name no matter where they occurred.
4. Where requested you decline to provide current
documentation relating to your credit rating or a
criminal history check.
5. You have outstanding debts or an adverse
criminal history check.
6. You are ineligible, or your new name is considered to
be a prohibited name i.e. obscene or offensive, too
long, includes symbols without phonetic significance,
cannot be established by repute or usage or is
considered to be against the public interest.
7. There is reason to believe that the application has
been made for fraudulent or improper purposes.
You will be notified in writing if your application is
unsuccessful.
^ƵƉƉŽƌƟŶŐĚŽĐƵŵĞŶƚĂƟŽŶ
1. Provide at least three (3) forms of identification
(ID) with your application.
See page 3
2. You must provide photo identification.
See pages 3 and 8
3. If you are applying in person, original documents
must be provided.
4. For postal applications all photocopies must be
clear and legible.
5. Proof of all previous legal name changes must be
presented (eg marriage certificate, name change,
deed poll, citizenship certificate).
6. Overseas documents must be translated into
English by an accredited National Accreditation
Authority for Translators and Interpreters (NAATI)
translator located in Australia.
Overseas translations will not be accepted.
7. Any other additional documents requested by the
Registry.
See page 7
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2
ŽƌŶŽǀĞƌƐĞĂƐ;KE>zͿ
1. If you are an ƵƐƚƌĂůŝĂŶĐŝƚŝnjĞŶďŽƌŶŽǀĞƌƐĞĂƐ,
your birth certificate, current passport and
citizenship certificate must be provided.
2. If born overseas and you are a ƉĞƌŵĂŶĞŶƚ
ƌĞƐŝĚĞŶƚ, your birth certificate, a current passport
and proof of your residency status must be
provided.
3. If born overseas, you must provide at least two
separate forms of documentary evidence that
you have been continuously living in WA for the
twelve (12) months immediately preceding your
application.
For detailed requirements refer to
/ĚĞŶƟĮĐĂƟŽŶ (page 3) and ZĞƐŝĚĞŶĐLJ (page 4).
ŚĞĐŬůŝƐƚ
Incomplete applications will cause delays and may
be refused. A checklist has been included to assist
you in ensuring you have met all of the requirements
prior to submitting your application.
See page 10
WƌŝǀĂĐLJΘĚŝƐĐůŽƐƵƌĞŽĨŝŶĨŽƌŵĂƟŽŶ
Information requested on this form is collected
under provisions of the Births, Deaths & Marriages
Registration Act 1998 and forms the basis to deter-
mine your eligibility to register a change of name.
Information held by the Registry may be provided to
government and non-government organisations for
purposes such as statistical and medical research and
to law enforcement agencies as well as other uses
provided for by law.
Any documents provided with this application may
have their authenticity verified through an approved
online verification service.
Documents issued by this office may also be verified
by other organisations using this service.
Refer to www.justice.wa.gov.au for more
information.
KƉƟŽŶƐƚŽůŽĚŐĞ
Submit your application form, payment and all supporting documents:
By mail:
Registry of Births, Deaths and Marriages
PO Box 7720, Cloisters Square
PERTH WA 6850
Do not mail original documents.
Only attach clear and legible photocopies
.
See page 3
/ŶƉĞƌƐŽŶ͗Level 10, 141 St Georges Terrace, PERTH
8.30am to 4.30pm, Monday to Friday
Enquiries: 1300 305 021
Website: www.justice.wa.gov.au
&ĂdžĞĚĂŶĚĞŵĂŝůĞĚĂƉƉůŝĐĂƟŽŶĨŽƌŵƐǁŝůůŶŽƚďĞĂĐĐĞƉƚĞĚ͘
WƌŽĐĞƐƐŝŶŐƟŵĞ
Allow a minimum of fifteen (15) working days to process your application, and a further ten (10) working days
if paying by personal cheque.
BDM400-C_Adult Change of Name Current Leg V4.indd 2BDM400-C_Adult Change of Name Current Leg V4.indd 2 17/11/20 14:5017/11/20 14:50
Proof you were born in Western Australia
WA birth certificate (original)
You must return all previously issued WA birth
certificates and WA change of name certificates.
>ŝƐƚϭͲ>ŝŶŬďĞƚǁĞĞŶƉŚŽƚŽĂŶĚƐŝŐŶĂƚƵƌĞ
>ŝƐƚϭͲ>ŝŶŬďĞƚǁĞĞŶƉŚŽƚŽĂŶĚƐŝŐŶĂƚƵƌĞ
Australian driver’s licence
Australian passport
Australian firearm’s licence
Defence Force/Police ID card
WA Photo Card, Over 18 or Proof of Age card
Australian learner driver’s permit card
If you can’t provide photo ID see page 8.
Australian driver’s licence
Australian passport
Australian firearm’s licence
Defence Force/Police ID card
Australian Citizenship Certificate
WA Photo Card, Over 18 or Proof of Age card
Australian learner driver’s permit card
If you can’t provide photo ID see page 8.
>ŝƐƚϮͲǀŝĚĞŶĐĞŽĨŶĂŵĞŝŶƚŚĞĐŽŵŵƵŶŝƚLJ
Debit/credit card
(one or the other, not both)
Entitlement card
issued by
Commonwealth/State
Government
(Centrelink, Health Care card, Veterans Affairs card etc)
Full Birth certificate issued in Australia
Medicare card
Security guard
or
crowd control licence
(Australian)
Student identity document or statement of
enrolment
issued by an educational institution,
including Tertiary
(include photo and/or signature)
Working with Children Check card
Debit/credit card
(one or the other, not both)
Document of identity
issued by the Passport Office
Entitlement card
issued by Commonwealth/State
Government
(Centrelink, Health Care card, Veterans Affairs card etc)
Medicare card
Naturalisation, citizenship or immigration
papers issued by the Department of Home Affairs
Overseas passport
with current Australian Entry Permit
Security guard
or
crowd control licence
(Australian)
Student identity document or statement of
enrolment
issued by an educational institution,
including Tertiary
(include photo and/or signature)
Working with Children Check card
>ŝƐƚϯͲWƌŽŽĨŽĨLJŽƵƌĐƵƌƌĞŶƚƌĞƐŝĚĞŶƟĂůƐƚĂƚƵƐ
Driver’s licence renewal notice
Motor vehicle registration
Financial institution statement
Property lease or tenancy agreement
Shire/water rates notice
School or other educational report or
certificate
less than twelve (12) months old
Utility account
(gas, electricity, home phone etc)
>ŝƐƚϯͲWƌŽŽĨŽĨLJŽƵƌĐƵƌƌĞŶƚƌĞƐŝĚĞŶƟĂůƐƚĂƚƵƐ
>ŝƐƚϮͲǀŝĚĞŶĐĞŽĨŶĂŵĞŝŶƚŚĞĐŽŵŵƵŶŝƚLJ
3
/ĚĞŶƟĮĐĂƟŽŶĂŶĚZĞƐŝĚĞŶĐLJ
You must provide at least three (3) forms of identification from the following lists:
• One document from each List
1, 2 and 3
;
KZ one from List 1 & two from List 2; OR two from List 2 & one from List 3.
• All forms of identification MUST be current (not expired).
• Documents from List 3 MUST show your current residential address and have an issue or expiry date
displayed
• Bank statements, utility accounts or rates notices MUST have been issued within the last six (6) months.
Applying in person - original documents must be provided.
Applying by post - enclose clear and legible photocopies of each identity document. Do not send original
documents with your application.
Born in WA
Born overseas
and residing in WA for the past 12 continuous months
Proof of your right to reside in Australia
Birth certificate
Current passport
If an Australian citizen your citizenship certificate, OR
If a permanent resident proof of your status as a
permanent resident
Driver’s licence renewal notice
Motor vehicle registration
Financial institution statement
Property lease or tenancy agreement
Shire/water rates notice
School or other educational report or
certificate
less than twelve (12) months old
Utility account
(gas, electricity, home phone etc)
BDM400-C_Adult Change of Name Current Leg V4.indd 3BDM400-C_Adult Change of Name Current Leg V4.indd 3 17/11/20 14:5017/11/20 14:50
4
KǀĞƌƐĞĂƐďŽƌŶKE>z
WƌŽŽĨŽĨƌĞƐŝĚĞŶĐLJŝŶt
You must be an ƵƐƚƌĂůŝĂŶĐŝƟnjĞŶ or ƉĞƌŵĂŶĞŶƚƌĞƐŝĚĞŶƚ of Australia.
,ŽǁƚŽƉƌŽǀĞLJŽƵƌƌĞƐŝĚĞŶĐLJ͗
• A ŵŝŶŝŵƵŵŽĨƚǁŽ;ϮͿ separate documents showing that you have been living continuously in WA for
ƚǁĞůǀĞ;ϭϮͿĐŽŶƐĞĐƵƚŝǀĞŵŽŶƚŚƐ before the date of your application.
• The documents must state your ĐƵƌƌĞŶƚĂĚĚƌĞƐƐ not PO BOX and where applicable all previous WA addresses within the
last twelve (12) months. Evidence should not be older than twelve (12) months (except your WA photo driver’s licence).
• The Registry will not accept any documents that do not have a date of issue displayed.
EŽƚĞ͗
• The Registry may make further enquiries about your living arrangements in the twelve (12) months prior to
your application before approving any change of name.
• The Registrar can refuse to register a change of name if you do not meet the requirements.
• If in doubt please contact the registry for advice.
džĂŵƉůĞƐŽĨĚŽĐƵŵĞŶƚƐ
ŽLJŽƵŽǁŶLJŽƵƌŚŽŵĞ͍ Or,ĚŽLJŽƵƌĞŶƚLJŽƵƌŚŽŵĞ͍
Rates notice
(WA Local Government Council)
Water rates
Utility bills
(gas, electricity, home phone etc)
Home insurance papers
Rent/Tenancy Agreement for a WA property
(covering the last twelve (12) months signed by the applicant and the owner)
Utility bills
(gas, electricity, home phone etc)
Contents insurance papers
ŽLJŽƵǁŽƌŬ͍
WA issued Working with Children Check card (current)
Official letter of confirmation from employer confirm-
ing the last twelve (12) months employment history
(including pay slips) showing applicant’s name and
pay period dates
Or,ĂƌĞLJŽƵƵŶĞŵƉůŽLJĞĚ͍
Centrelink card showing your name and WA address
(issued a minimum twelve (12) months ago)
Centrelink correspondence on letterhead showing
your past twelve (12) months residential addresses as
recorded by them
ŽLJŽƵŚĂǀĞĂĚƌŝǀĞƌ͛ƐůŝĐĞŶĐĞŽƌŽǁŶĂǀĞŚŝĐůĞ͍
WA Driver’s licence (current) - if photocopy provided,
must include both sides
Registration papers
Infringement notices
(WA Fines Enforcement agency)
ŽLJŽƵŚĂǀĞĂtďŝƌƚŚ;ĐŚŝůĚͿŽƌŵĂƌƌŝĂŐĞĐĞƌƟĮĐĂƚĞ͍
School reports for children of the applicant showing the
attendance records for the last twelve (12) months
Medical records for the applicant or their children
within the last twelve (12) months issued by a WA
based medical centre or health care nurse
ŽLJŽƵŚĂǀĞƐĐŚŽŽůƌĞƉŽƌƚƐŽƌŵĞĚŝĐĂůƌĞĐŽƌĚƐ͍
A birth certificate of a family member (child) born in
WA in the past twelve (12) months where the appli-
cant(s) is listed on the certificate as a family member
A marriage certificate involving the applicant(s) that took
place in WA within the past twelve (12) months showing
the same address
Official correspondence from a WA State or Local Government
agency (not this office) not less than three (3) months old but
within twelve (12) months showing WA residential address
Proof of lodgement of the Permanent Resident Sta
-
tus Visa application showing a WA address lodged
twelve (12) months but not more than two (2) years ago in
conjunction with the applicant’s current passport
Evidence of the applicant’s interaction with a WA based
law enforcement agency or court within the past
twelve (12) months
tŚĂƚŽƚŚĞƌĚŽĐƵŵĞŶƚƐĚŽLJŽƵŚĂǀĞ͍
Bank statements showing transactions made within
WA for the twelve (12) months immediately preceding
the date of your application
ŽLJŽƵŚĂǀĞĂďĂŶŬĂĐĐŽƵŶƚ͍
BDM400-C_Adult Change of Name Current Leg V4.indd 4BDM400-C_Adult Change of Name Current Leg V4.indd 4 17/11/20 14:5017/11/20 14:50
5
&ĂůƐĞ/ŶĨŽƌŵĂƟŽŶ
It is an offence to make a false or misleading statement in any application or document under the
Births, Deaths, and Marriages Registration Act 1998
. Penalties apply.
/ŶƐƚƌƵĐƟŽŶƐĨŽƌĐŽŵƉůĞƟŶŐƚŚŝƐĂƉƉůŝĐĂƟŽŶ
• Print clearly with black ink only.
• Symbols and abbreviations must not be used.
• To make an alteration, cross out the mistake and ŝŶŝƚŝĂůƚŚĞĐŚĂŶŐĞ͘
• Do not use correction fluid or tape.
• Do not fax or email the application form.
• If any requirements are not met, the application will not be accepted.
• If you do not provide any additional information requested by the Registry within 28 days, your application
will be cancelled and retained. A refund of any payment will be processed separately.
WZdϭ͗^ĐƌĞĞŶŝŶŐYƵĞƐƟŽŶƐ
ϭ͘ tŚĞƌĞǁĞƌĞLJŽƵďŽƌŶ͍
WA
Go to question 3
Overseas
Go to question 2
Interstate
Apply with the Registry in the
State or Territory you were born
Ϯ͘ ,ĂǀĞLJŽƵďĞĞŶůŝǀŝŶŐŝŶtĐŽŶƚŝŶƵŽƵƐůLJĨŽƌƚŚĞ
ƉĂƐƚƚǁĞůǀĞ;ϭϮͿŵŽŶƚŚƐďĞĨŽƌĞƚŚĞĚĂƚĞŽĨƚŚŝƐ
ĂƉƉůŝĐĂƚŝŽŶ͍
YES
Go to question 3
NO
You cannot apply for a change of name in WA
ϯ͘ ,ĂǀĞLJŽƵĂůƌĞĂĚLJĐŚĂŶŐĞĚLJŽƵƌŶĂŵĞďLJ
ƌĞŐŝƐƚƌĂƚŝŽŶǁŝƚŚŝŶƚŚĞůĂƐƚƚǁĞůǀĞ;ϭϮͿŵŽŶƚŚƐ
ďĞĨŽƌĞƚŚĞĚĂƚĞŽĨƚŚŝƐĂƉƉůŝĐĂƚŝŽŶ͍
YES
You cannot apply for a change of name in WA
NO Go to PART 2
WZdϮ͗zŽƵƌďŝƌƚŚĚĞƚĂŝůƐ
Your Family name at birth (surname)
Your 'ŝǀĞŶŶĂŵĞ;ƐͿ at birth
ĂƚĞŽĨďŝƌƚŚ
D D M M Y Y Y Y
WůĂĐĞŽĨďŝƌƚŚ
Suburb/Town
State Country
Born overseas, you are either:
ĂŶƵƐƚƌĂůŝĂŶĐŝƟnjĞŶ͘ You must supply:
- your birth certificate;
- a current passport;
- citizenship certificate; and
- proof of your residency status.
a ƉĞƌŵĂŶĞŶƚƌĞƐŝĚĞŶƚ. You must supply:
- your birth certificate;
- a current passport; and
- proof of your residency status.
WZdϯ͗WĂƌĞŶƚƐ͛ĚĞƚĂŝůƐĂƐƌĞĐŽƌĚĞĚŽŶLJŽƵƌ
ďŝƌƚŚĐĞƌƟĮĐĂƚĞ
ϭ͘ WĂƌĞŶƚKŶĞ͛ƐCurrent family name (surname)
Family name at their birth (maiden name)
Given name(s)
Ϯ͘ WĂƌĞŶƚdǁŽ͛Ɛ Current family name (surname)
Given name(s)
Family name at their birth (maiden name)
ZĞŐŝƐƚĞƌĂĐŚĂŶŐĞŽĨŶĂŵĞ
(adult 18 years or over)
BDM400-C
ƉƉůŝĐĂƚŝŽŶƐƚĂƌƚƐŚĞƌĞ
Sex
Male
Female
BDM400-C_Adult Change of Name Current Leg V4.indd 5BDM400-C_Adult Change of Name Current Leg V4.indd 5 17/11/20 14:5017/11/20 14:50
6
Marital status
Single
Married De facto
Divorced
Widowed Separated
WZdϰ͗DĂƌƌŝĂŐĞĚĞƚĂŝůƐ (if applicable)
&ƵůůŶĂŵĞƉƌŝŽƌƚŽůĂƐƚŵĂƌƌŝĂŐĞ - marriage certificate(s) must be provided
ĞƚĂŝůƐŽĨLJŽƵƌĐŚĂŶŐĞŽĨŶĂŵĞ
PART 7:
ZĞĂƐŽŶ;ƐͿĨŽƌĐŚĂŶŐŝŶŐLJŽƵƌŶĂŵĞ
You must provide a detailed reason for changing your surname and/or given name(s) for your application to be
considered.
One or two word explanations such as personal, professional, passport or driver’s licence are not sufficient and
your application may be declined.
Please supply any relevant documents to support your application (eg your overseas marriage certificate).
You can write your reason on a separate page if there is not enough space below.
Date of Marriage
Place of Marriage
(suburb/town, state, country)
First marriage
/ /
^ĞĐŽŶĚŵĂƌƌŝĂŐĞ
/ /
dŚŝƌĚŵĂƌƌŝĂŐĞ
/ /
&ŽƵƌƚŚŵĂƌƌŝĂŐĞ
/ /
PART 5:
zŽƵƌĐƵƌƌĞŶƚŶĂŵĞ
;ED,E'/E'&ZKDͿ
WZdϲ͗EĂŵĞLJŽƵǁĂŶƚƚŽƌĞŐŝƐƚĞƌ;EtEDͿ
Current Family name (surname)
EĞǁ Family name (surname)
Current Given name(s)
EĞǁ Given name(s)
BDM400-C_Adult Change of Name Current Leg V4.indd 6BDM400-C_Adult Change of Name Current Leg V4.indd 6 17/11/20 14:5017/11/20 14:50
7
^ƵƉƉŽƌƚŝŶŐŝŶĨŽƌŵĂƚŝŽŶ
PART 8:
Previous names
,ĂǀĞLJŽƵƉƌĞǀŝŽƵƐůLJĐŚĂŶŐĞĚLJŽƵƌŶĂŵĞ;ůĞŐĂůůLJͿŝŶƵƐƚƌĂůŝĂŽƌŽǀĞƌƐĞĂƐ;ŝŶĐůƵĚŝŶŐŵĂƌƌŝĂŐĞͿ͍
NO
Go to PART 9
YES
You must provide details below of each name used and evidence of how you changed your name.
Failure to list all previous names may result in your application being declined.
Note: - this also includes a change of name by marriage.
- copies of these documents must be provided
(see Supporting documentation page 1).
PART 9:
ĚĚŝƟŽŶĂůŝŶĨŽƌŵĂƟŽŶ
ϭ͘ ,ĂǀĞLJŽƵĞǀĞƌŚĂĚĂŶĂƉƉůŝĐĂƚŝŽŶƚŽĐŚĂŶŐĞLJŽƵƌŶĂŵĞƌĞĨƵƐĞĚŝŶĂŶLJƵƐƚƌĂůŝĂŶ^ƚĂƚĞŽƌdĞƌƌŝƚŽƌLJ͍
If you had more than one refused application provide all details on a separate attachment.
NO Go to Question 2
YES Application Date
Where
Reason for refusal
Ϯ͘ ŽLJŽƵŚĂǀĞĂŶLJĨŝŶĂŶĐŝĂůĚĞĨĂƵůƚƐ͍
NO Go to Question 3
YES You must attach a copy of your credit report under your current name and all names you
have previously used.
ϯ͘ ,ĂǀĞLJŽƵĞǀĞƌďĞĞŶĚĞĐůĂƌĞĚďĂŶŬƌƵƉƚ͍
NO Go to Question 4
YES You must attach a letter which acknowledges your bankruptcy from the Australian Financial
Security Authority or from your Trustee in Bankruptcy.
ϰ͘ ,ĂǀĞLJŽƵĞǀĞƌďĞĞŶĂƌƌĞƐƚĞĚ͕ĐŚĂƌŐĞĚ͕ŽŶďĂŝůŽƌĐŽŶǀŝĐƚĞĚŽĨĂĨƌĂƵĚƌĞůĂƚĞĚŽĨĨĞŶĐĞ͍
NO Go to PART 10
YES You must attach a statutory declaration explaining the circumstances.
D D M M Y Y Y Y
BDM400-C_Adult Change of Name Current Leg V4.indd 7BDM400-C_Adult Change of Name Current Leg V4.indd 7 17/11/20 14:5017/11/20 14:50
Family name
(surname)
Given name(s)
Date
changed
Where changed
(Australian State/
Territory or overseas
country)
How changed
(name change,
deed poll, marriage)
/ /
/ /
/ /
/ /
/ /
/ /
8
Photo identification
WZdϭϬ͗
WŚŽƚŽĂŶĚ/ĚĞŶƟƚLJĚŽĐƵŵĞŶƚƐ
ϭ͘ ƌĞĂůůLJŽƵƌŝĚĞŶƚŝƚLJĚŽĐƵŵĞŶƚƐŝŶLJŽƵƌĐƵƌƌĞŶƚ
ŶĂŵĞ͍;Ğ͘Ő͘ĚƌŝǀĞƌ͛ƐůŝĐĞŶĐĞ͕ƉĂƐƐƉŽƌƚ͕DĞĚŝĐĂƌĞ
ĐĂƌĚͿ
YES 'ŽƚŽYƵĞƐƟŽŶϮ
NO
Please specify why not.
If not enough space below write your
ĞdžƉůĂŶĂƟŽŶŽŶĂƐĞƉĂƌĂƚĞĂƩĂĐŚŵĞŶƚ͘
Ϯ͘ ,ĂǀĞLJŽƵƐƵƉƉůŝĞĚĂŶŝĚĞŶƚŝƚLJĚŽĐƵŵĞŶƚĨƌŽŵ>ŝƐƚϭ͍
Yes Go to PART 11
NO
You must provide ƚǁŽ;ϮͿ recent passport sized
photographs signed on the back by a
Guarantor
• Must be a professional passport photo standard.
• Be no more than three (3) months old.
• Show only head and top of shoulders.
• Be between 35mm and 40mm wide and between
45mm and 50mm high.
• Be printed on photographic paper, with no marks on
the image.
• Show you without any hat or other head covering.
• If you wear a head covering for religious reasons,
the photos must show your face from the bottom
of the chin to the top of the forehead and both
edges of your face.
• Be attached to this form with a paperclip (do not
staple).
• Be signed on the back by a Guarantor along with
your name and signature.
The Guarantor must:
• not be related to you by birth or marriage.
• not be a de facto partner.
• not live at the same address as you.
• be 18 years of age or over.
• have known you for at least one (1) year.
35-40mm
Min 32mm
Max 36mm
45-50mm
Front of photo size
DO NOT ATTACH
Guarantor must endorse
on the back of the photo
This is a true
photo of
____________
full name of subject
____________
signature of subject
_____________
signature of Guarantor
WŚŽƚŽŐƌĂƉŚ
'ƵĂƌĂŶƚŽƌ͛ƐĚĞƚĂŝůƐ
Family name (surname)
'ŝǀĞŶŶĂŵĞ;ƐͿ
• I declare that the information I have provided
is true and correct to my knowledge and that I
qualify to be a Guarantor for the person changing
their name in this application.
• I
understand that the WA Registry of Births, Deaths
and Marriages may make enquiries with any
organisation or individual to verify the information
I have provided on this
form.
'ƵĂƌĂŶƚŽƌ͛ƐĚĞĐůĂƌĂƟŽŶ
Date
D D M M Y Y Y Y
,ŽǁůŽŶŐŚĂǀĞLJŽƵŬŶŽǁŶƚŚĞĂƉƉůŝĐĂŶƚ͍
Daytime phone number
,ŽǁĚŽLJŽƵŬŶŽǁƚŚĞĂƉƉůŝĐĂŶƚ͍ (eg doctor, friend)
years
ŵŽŶƚŚƐ
Y Y M M
ƵƌƌĞŶƚƌĞƐŝĚĞŶƟĂůĂĚĚƌĞƐƐ (PO Boxes not accepted)
Street number and name
Suburb/Town
PostcodeState
Guarantor’s signature
BDM400-C_Adult Change of Name Current Leg V4.indd 8BDM400-C_Adult Change of Name Current Leg V4.indd 8 17/11/20 14:5117/11/20 14:51
9
/ĚĞĐůĂƌĞƚŚĂƚ͗
• The information I have provided in this application is true and correct.
• I am a resident or was born in Western Australia.
• I wish to be known by the new name (legal name) stated in Part 6 of this form.
• I acknowledge I have checked and certify the new name as being completely accurate.
• I understand that I will not be able to register a change of name again within twelve (12) months without
exceptional circumstances such as personal safety.
/ƵŶĚĞƌƐƚĂŶĚƚŚĂƚ͗
• This application is a legal process and once registered the change of name cannot be cancelled or changed
and a refund of the application fee cannot be provided.
• This form remains the property of the State of WA and that some or all of the information may be disclosed
to persons or bodies with adequate entitlement to the information under the
Births, Deaths & Marriages
Registration Act 1998
or the Registry’s Access policy.
• It is an offence to make a false or misleading representation in this application or its supporting documents
and that penalties may apply.
• By signing the change of name application I consent to my information being checked with the document issuer
or official record holder and understand the Registry may make additional checks with organisations such as the
Passport Office, Police Department, Corrective Services, Department of Home Affairs and credit reference agencies.
/ĐĞƌƟĨLJƚŚĂƚ/ŚĂǀĞƌĞĂĚĂŶĚƵŶĚĞƌƐƚŽŽĚƚŚĞĚĞĐůĂƌĂƟŽŶĂďŽǀĞ͘
Applicant’s signature
Date
D D M M Y Y Y Y
zŽƵƌĚĞĐůĂƌĂƚŝŽŶ
WZdϭϭ͗ĞĐůĂƌĂƟŽŶ
Your current full name
Current residential address (PO Boxes not accepted)
State
Postcode
Suburb/Town
Email address
Daytime phone number
What is your preferred method of contact
Email
PhoneMail
BDM400-C_Adult Change of Name Current Leg V4.indd 9BDM400-C_Adult Change of Name Current Leg V4.indd 9 17/11/20 14:5117/11/20 14:51
10
ŚĞĐŬůŝƐƚ
tŽƌŶKE>z
KǀĞƌƐĞĂƐŽƌŶKE>z
I am 18 years of age or older.
/ŚĂǀĞĐŽŵƉůĞƚĞĚƚŚĞĨŽůůŽǁŝŶŐ͗
WĂƌƚϭ - Screening questions.
WĂƌƚϮ - Your birth details.
WĂƌƚϯ - Parents’ details.
Part 4 - Marriage details (if applicable).
Part 5 - Your current name
(name changing from).
Part 6 - Name you want to register
(new name).
Part 7 - Reason(s) for changing your name.
Part 8 - Previous names - I have disclosed and
provided copies of all current & previous change
of name(s).
Part 9 - Additional information - If I answered
YES to any of these questions I have
attached all relevant documentation.
Part ϭϬ - Photo & Identity documents - I have
supplied all three (3) identity documents listed
on page 3. If I don’t have photo identification
from List 1 I have supplied two passport photos
which have been signed by a guarantor.
Part ϭϭ
- Your declaration -
I have completed and
signed the declaration on page 9.
KƌĚĞƌĨŽƌŵ - Completed page 11.
/ŚĂǀĞĂůƐŽƉƌŽǀŝĚĞĚƚŚĞĨŽůůŽǁŝŶŐ͗
My marriage certificate(s) (if applicable).
Original WA birth certificate.
All required supporting documents.
/ŚĂǀĞĂůƐŽƉƌŽǀŝĚĞĚƚŚĞĨŽůůŽǁŝŶŐ͗
My marriage certificate(s) (if applicable).
My birth certificate.
My passport.
If I am an ƵƐƚƌĂůŝĂŶŝƚŝnjĞŶ I have provided my
Citizenship Certificate.
If I am a ƉĞƌŵĂŶĞŶƚƌĞƐŝĚĞŶƚ I have provided
proof of my residency status.
Residency documents - I currently live in WA and
have provided at least two (2) residency docu
-
ments showing evidence of living here continu-
ously for at least twelve (12) months.
All required supporting documents.
EŽƚĞ͗ Overseas documents must be translated into English
by an accredited NAATI translator located in Australia.
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/ĨĂƉƉůLJŝŶŐďLJŵĂŝů͗
I have included clear and legible photocopies
of my identity documents
I have included payment or completed the
Credit Card Payment Slip on page 11.
I am 18 years of age or older.
/ŚĂǀĞĐŽŵƉůĞƚĞĚƚŚĞĨŽůůŽǁŝŶŐ͗
WĂƌƚϭ - Screening questions.
WĂƌƚϮ - Your birth details.
WĂƌƚϯ- Parents’ details.
Part 4 - Marriage details (if applicable).
Part 5 - Your current name
(name changing from).
Part 6 - Name you want to register
(new name).
Part 7 - Reason(s) for changing your name.
Part 8 - Previous names - I have disclosed and
provided copies of all current & previous change
of name(s).
Part 9 - Additional information - If I answered
YES to any of these questions I have
attached all relevant documentation.
Part ϭϬ - Photo & Identity documents - I have
supplied all three (3) identity documents listed
on page 3. If I don’t have photo identification
from List 1 I have supplied two passport photos
which have been signed by a guarantor.
Part ϭϭ
- Your declaration -
I have completed and
signed the declaration on page 9.
KƌĚĞƌĨŽƌŵ - Completed page 11.
/ĨĂƉƉůLJŝŶŐďLJŵĂŝů͗
I have included clear and legible photocopies
of my identity documents.
I have included payment or completed the
Credit Card Payment Slip on page 11.
BDM400-C_Adult Change of Name Current Leg V4.indd 10BDM400-C_Adult Change of Name Current Leg V4.indd 10 17/11/20 14:5117/11/20 14:51
11
Fees
The fee to register a change of name is $185 and is payable when submitting this form.
Please note:
• Family applications - Where a family apply to change their name together all applications for children of
that family under 18 years of age are not charged a fee ie each adult applicant pays a full fee and each child
no fee payable.
• A separate fee is payable for all change of name certificates.
• Any person who is born in WA will have the new name noted at the bottom of their birth certificate.
• If born in WA and you have a birth certificate you must return it with this application. It will be replaced
FREE of charge upon registration of your change of name. Otherwise a separate fee is payable.
Street number and name or PO Box
Suburb/Town
Name
Postcode
State
Mail the certificate(s) to:
Postal address - provide details below
My residential address
(per the Declaration on page 9)
Credit card payment (mail applications only)
Only complete this section onceonce if part of a family application
Total $
.
Applicant’s surname
Card type
MasterCard
Visa
Card number
Expiry date
Name on card (please print) Signature of cardholder
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Product / Service Price
+
Qty Subtotal
Registration of change of name
$185
$
Change of name certificate
$53
$
Full WA birth certificate
(only if born in WA)
$53
$
+
All prices listed are subject to change.
Confirm current fees at www.justice.wa.gov.au
Total
$
Order form
Payment details
1. What type of application is this?
Family application
Single application
Complete payment details on one
application form only
Enclosed is the following:
2. How do you wish to pay?
Credit card
Complete the Credit Card Payment Slip
Cheque
Allow an extra ten (10) working days for personal cheques
Money order
By mail
Make cheque or money order payable to the
Registrar of Births, Deaths & Marriages
In person
The Registry accepts cash, credit cards, EFTPOS,
money orders, bank and personal cheques.
Allow an extra ten (10) working days for personal cheques
Family applications:
• Fill out payment details on one application form only.
• Enter the change of name registration fee of $185, plus the total of any certificate(s) requested and forward
payment to the Registry.
BDM400-C_Adult Change of Name Current Leg V4.indd 11BDM400-C_Adult Change of Name Current Leg V4.indd 11 17/11/20 14:5117/11/20 14:51
Registry of Births, Deaths & Marriages
Address: Level 10, 141 St Georges Terrace, PERTH WA 6000 | Phone: 1300 305 021 | Website:
OFFICE USE ONLY
______________________________________
______________________________________
12
BDM-400-C | JULY21
BDM400-C_Adult Change of Name Current Leg V4.indd 12BDM400-C_Adult Change of Name Current Leg V4.indd 12 17/11/20 14:5117/11/20 14:51
www.justice.wa.gov.au
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change of namechange of name Application to register (Services Australia)

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Completed 14 March 2022

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