Statutory Declaration Sample Form

State of Victoria
Statutory Declaration
I,
[full 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
belief that a person who makes a false declaration is liable to the penalties of perjury.
Declared at
this
day of 20 ……………………………………...
Signature of person making this declaration
[to be signed in front of an authorised witness]
Before me,
………………………………………………
Signat ure of A uth ori sed Witness
The authorised witness must print or stamp his or her name, address and title under section 107A of the Evidence
(Miscellaneous Provisions) Act 1958 (as of 1 January 2010), (previously Eviden ce Act 1958), (eg. Justice of the Peace,
Pharmacist, Police Officer, Court Registrar, Bank Manager, Medical Practi tione r, Dentist)
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