Commonwealth of Australia Statutory Declaration

Commonwealth of Australia
STATUTORY DECLARATION
Statutory Declarations Act 1959
1
Insert the name,
a
ddress and
occupation of
person making
the declaration
I,
1
make the following declaration under the Statutory Declarations Act 1959:
2 Set out matter
declared to in
numbered
paragraphs
2
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.
3 Signature of
person making
the declaration
3
4 Place
5 Day
6 Month and year
Declared at
4
on
5
of
6
Before me,
7 Signature of
person before
whom the
declaration is
made (see over)
7
8 Full name,
qualification and
address of person
before whom the
declaration is
made (in printed
letters)
8
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.
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