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					IN THE SUPREME COURT OF VICTORIA AT MELBOURNE

                                                                             No.   of 20

                                               DIVISION/COURT OF APPEAL


BETWEEN


                                                  Plaintiff/Applicant/Appellant

–   and –


                                                  Defendant/Respondent

                                   AFFIDAVIT OF


Date of document:
Filed on behalf of:
Prepared by:                                      Tel:
                                                  Fax:


I,…………………………………, ………………… ,of …………………………….., [make
oath and say or solemnly and sincerely affirm] as follows:

    1.      That I am the………………………….. in this matter and I make this affidavit
            from my own knowledge unless otherwise stated.
    2.

    3.

SWORN or AFFIRMED at
in the State of Victoria
this …………..… day of ………………… 20


BEFORE ME:

				
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