Statutory Declaration Form - City of Melbourne

St ate of V i ctori a – E vi dence Ac t 1958
[JP/DOJ.1/2000]
STATUTORY DECLARATION
I
, ___________________________________________________________________ ,
[f ul l name]
of ___________________________________________________________________ ,
[address]
_______________________________ , do solemnly and sincerely declare that:-
[occupation]
I acknowledge that this declaration is true and correct, and I make it with the understanding
and beli ef t hat a person who makes a false declarat i on i s l iable t o t he penal t ies of perjury.
Declared at _________________________
in the St ate of Victor ia, this _______ day of
___________________ 20 ____ .........................................................
Signature of person m aking t hi s decl aration
[t o be signed in front of an authoris ed witnes s]
Before me,
............................................
Signature of authorised witness
The authori s ed witness must pri nt or stamp hi s or her nam e, address, and t i tle under s ecti on 107A of the E vidence Act 1958 [ Vic.]
(eg. Just i ce of the Peace, P harmacis t, P ol i ce Off i cer, Court Regis trar, B ank Manager, Medical Pract i tioner, Dentis t)
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