Benefit Application - Financial Hardship by lae10162

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									Benefit Application -
Financial Hardship                                                                                                                straightfor ward.simple.fair.




 Guidelines for completing this form                                                           Important Notice
 Legislation allows AGEST to release benefits to members prior to their                       Please note the following before you complete this form:
 retirement in cases of severe financial hardship.
                                                                                                ► Benefit payments from your account may impact any insurance cover
 Under the legislation, AGEST must be satisfied that, based on written                            you have in AGEST.
 evidence provided by at least one Commonwealth department or agency
                                                                                                ► You will need to provide proof of identity to enable a benefit to be
 responsible for administering a class of Commonwealth income support
                                                                                                  paid to you.
 payments:
    ► you have been receiving Commonwealth income support payments
                                                                                                      >   the identification documents you need to supply are outlined
                                                                                                          later in this document.
      for a continuous period of at least 26 weeks; and
                                                                                                      >   Any documents you provide will be stored securely and will only
    ► you were in receipt of payments of that kind on the date of the written                             be used for the purpose of proving your identity in relation to this
      evidence; and                                                                                       benefit.
    ► you are unable to meet reasonable and immediate family living                                   >   your identification details may be independently verified.
      expenses.
                                                                                                      >   faxed copies of certified documents are not acceptable and you
                                                                                                          should not send original identification documents.
 The benefit payable is restricted to a single lump sum in any 12-month
 period, up to a maximum of $10,000 (gross). In most cases, tax will
                                                                                                      >   You should contact us on 1300 724 378 if you are unable to
                                                                                                          provide this proof of identity.
 need to be deducted from the benefit prior to payment.
                                                                                                ► The unit prices used to update your account can go up or down,
                                                                                                  depending on movements in investment markets. You can view the
 Alternatively, if you have reached your preservation age (currently age 55)                      latest prices on our website, www.agest.com.au, or obtain them by
 plus 39 weeks, an alternative optional test applies. In such cases, AGEST                        contacting us on 1300 724 378. Unit prices change daily and are
 must be satisfied that, based on written evidence provided by at least one                       posted on our website.
 Commonwealth department or agency responsible for administering a
 class of Commonwealth income support payments:                                                 ► AGEST's Product Disclosure Statement (PDS) contains important
                                                                                                  information regarding your AGEST benefits, including an explanation
    ► you have been receiving Commonwealth income support payments                                of the unit prices that are used when processing your benefit. You
      for a cumulative period of at least 39 weeks after you reached your                         should read the PDS before making an investment decision.
      preservation age; and
    ► you were not gainfully employed on a full-time, or part-time, basis
      on the date of the application for cashing your preserved benefits, or                  Providing us with your Tax File Number (TFN)
      restricted non-preserved benefits.
                                                                                              You do not have to provide your TFN but if you don't, there will be a number
 If you have reached your preservation age and satisfy the latter test, then                  of implications:
 your entire benefit may be released. In all cases the written evidence
                                                                                                ► AGEST will be prohibited by law from accepting personal after-tax
 provided must not be dated more than 21 days before the date of your                             (non-concessional) contributions from you.
 application for a benefit.
                                                                                                ► any concessional contributions received for you will be taxed at
 Please note that this form only relates to “severe financial hardship”                           46.5% (that is, the normal 15% contributions tax + an additional
 applications. If you would like to enquire about accessing your benefits on                      31.5% penalty tax).
 the basis of “compassionate grounds” you should contact APRA on
 1300 131 060.                                                                                  ► it may be more difficult for AGEST to locate and amalgamate your
                                                                                                  superannuation benefits in the future, and to pay your full benefit
                                                                                                  entitlement.
 How to apply
                                                                                                ► the Australian Taxation Office (ATO) may be unable to pay you a
 To apply to AGEST for a benefit on the grounds of severe financial hardship,                     co-contribution.
 you must provide all of the following:
                                                                                                ► your superannuation benefit may be taxed at a higher rate than
    ► Evidence of receipt of eligible income support payments.                                    necessary when you withdraw your benefit from the fund.
      This should be in the form of a Release of Superannuation Benefits
      on Hardship Grounds - Income Support Requirements Met letter from                       Further details on providing your TFN are located on AGEST's Product
      Centrelink (reference number Q230) or Veterans Affairs.                                 Disclosure Statement (PDS).
                                                                                              Your TFN can be provided on the form attached. You can also provide your
        A list of Eligible Commonwealth Government Income Support                             TFN by:
        Payments is shown on the next page. AGEST cannot assess your
        application if you are unable, or ineligible, to provide one of the above               ► logging into your account at www.agest.com.au
        letters.                                                                                ► calling us on 1300 724 378
    ► A completed Benefit Application (Financial Hardship) form.
      Ensure the Statutory Declaration is completed, witnessed, signed and
      dated. The information you supply on the form will be used by AGEST                     Proving your identity
      to assess your eligibility for a benefit. Please help us by ensuring
                                                                                              To comply with government legislation, you must provide proof of your
      that the form is completed fully and correctly and that all relevant
                                                                                              identity (as outlined in the next section). All copied pages of ORIGINAL
      information is provided.
                                                                                              proof of identification documents (including any linking documents as
    ► Appropriate documentation to support your financial hardship                            described later in this document) must be certified as true copies by any
      claim.                                                                                  individual approved to do so (see next page).
      Wherever possible, you should provide copies of outstanding bills,
                                                                                              The person who is authorised to certify documents must sight the original
      statutory declarations relating to debts owing to family or friends that
                                                                                              and the copy and make sure both documents are identical, then make
      need to be paid immediately, or any other documents you feel would
                                                                                              sure all pages have been certified as true copies by writing or stamping
      support your application.
                                                                                              ‘certified true copy’ followed by their signature, printed name, qualification
    ► Certified proof of identification as outlined on this form.                             (eg Justice of the Peace, Australia Post employee, etc) and date. The
                                                                                              following can certify copies of the originals as true and correct copies:

This document was prepared 25 May 2009 by AGEST Super Pty Ltd [ABN 44 007 390 392, RSE Licence L0000383, AFS Licence 233 707], the trustee of AGEST.
The contents of this brochure are of a general nature and have been prepared without taking into account your particular financial needs, circumstances or objectives. You should
assess your own financial situation and read AGEST’s combined Product Disclosure Statement and Financial Services Guide before making an investment decision.
Benefit Application -
Financial Hardship                                                                                                straightfor ward.simple.fair.




  ► a judge of a court;                                                                >    if it is written in a language that is not understood by the person
                                                                                            carrying out the verification is accompanied by an English
  ► a magistrate;
                                                                                            translation prepared by an accredited translator;
  ► a chief executive officer of a Commonwealth court;
  ► a registrar or deputy registrar of a court;                                  'Primary non photographic identification' document means any of the
  ► a Justice of the Peace;                                                      following:
  ► a notary public (for the purposes of the Statutory Declaration                 ► a birth certificate or birth extract issued by a State or Territory;
    Regulations 1993);
                                                                                   ► a citizenship certificate issued by the Commonwealth;
  ► a police officer;
                                                                                   ► a citizenship certificate issued by a foreign government that, if it is
  ► an agent of the Australian Postal Corporation who is in charge of an             written in a language that is not understood by the person carrying
    office supplying postal services to the public;                                  out the verification, is accompanied by an English translation prepared
                                                                                     by an accredited translator;
  ► a permanent employee of the Australian Postal Corporation with 2
    or more years of continuous service who is employed in an office               ► a birth certificate issued by a foreign government, the United Nations
    supplying postal services to the public;                                         or an agency of the United Nations that, if it is written in a language
                                                                                     that is not understood by the person carrying out the verification, is
  ► an Australian consular officer or an Australian diplomatic officer (within
                                                                                     accompanied by an English translation prepared by an accredited
    the meaning of the Consular Fees Act 1955);
                                                                                     translator;
  ► an officer with 2 or more continuous years of service with one or more
                                                                                   ► a pension card issued by Centrelink that entitles the person in whose
    financial institutions (for the purposes of the Statutory Declaration
                                                                                     name the card is issued, to financial benefits.
    Regulations 1993);
  ► a finance company officer with 2 or more continuous years of
    service with one or more finance companies (for the purposes of the          'Secondary identification' document means any of the following:
    Statutory Declaration Regulations 1993);                                       ► a notice that:
  ► an officer with, or authorised representative of, a holder of an                   >    was issued to an individual by the Commonwealth, a State or
    Australian financial services licence, having 2 or more continuous                      Territory within the preceding twelve months;
    years of service with one or more licensees.                                       >    contains the name of the individual and his or her residential
  ► a member of the Institute of Chartered Accountants in Australia, CPA                    address; and
    Australia or the National Institute of Accountants with 2 or more years
    of continuous membership.
                                                                                       >    records the provision of financial benefits to the individual under
                                                                                            a law of the Commonwealth, State or Territory (as the case may
                                                                                            be);
Proof of Identity documents
                                                                                   ► a notice that:
You must provide either:
                                                                                       >    was issued to an individual by the Australian Taxation Office
  ► ONE certified copy of a 'primary photographic identification'                           within the preceding 12 months;
    document (as defined below); OR
                                                                                       >    contains the name of the individual and his or her residential
  ► both                                                                                    address; and
      >    a certified copy of ONE 'primary non photographic                           >    records a debt payable to or by the individual by or to
           identification' document (as defined below); and                                 (respectively) the Commonwealth under a Commonwealth law
      >    a certified copy of ONE 'secondary identification' document (as                  relating to taxation;
           defined below).                                                         ► a notice that:
                                                                                       >    was issued to an individual by a local government body or
'Primary photographic identification' document means any of the                             utilities provider within the preceding three months;
following:                                                                             >    contains the name of the individual and his or her residential
  ► a licence or permit issued under a law of a State or Territory or                       address; and
    equivalent authority of a foreign country for the purpose of driving a             >    records the provision of services by that local government body
    vehicle that contains a photograph of the person in whose name the                      or utilities provider to that address or to that person.
    document is issued;
                                                                                   ► In relation to a person under the age of 18, a notice that:
  ► a passport issued by the Commonwealth;
                                                                                       >    was issued to a person by a school principal within the
  ► a passport or a similar document issued for the purpose of                              preceding three months;
    international travel, that:
      >                                                                                >    contains the name of the person and his or her residential
           contains a photograph and the signature of the person in whose                   address; and
           name the document is issued;
      >                                                                                >    records the period of time that the person attended at the
           is issued by a foreign government, the United Nations or an                      school.
           agency of the United Nations; and
      >    If it is written in a language that is not understood by the person   Linking Documents
           carrying out the verification is accompanied by an English
           translation prepared by an accredited translator.                     If you have changed your name or are signing on behalf of the applicant,
                                                                                 you will need to provide a certified linking document. A linking document
  ► a card issued under a law of a State or Territory for the purpose of         is a document that proves a relationship between two (or more) names.
    proving the person’s age which contains a photograph of the person
    in whose name the document is issued.                                        The following table contains information about suitable linking documents.

  ► a national identity card issued for the purpose of identification, that:      Purpose                   Suitable linking documents
      >    contains a photograph and the signature of the person in whose         Change of name            Marriage certificate, deed poll or change of
           name the document is issued;                                                                     name certificate from the Births, Deaths and
      >    is issued by a foreign government, the United Nations or an
                                                                                                            Marriages Registration Office.
           agency of the United Nations; and                                      Signed on behalf of       Guardianship papers or Power of Attorney.
                                                                                  applicant
Benefit Application -
Financial Hardship                                                                                            straightfor ward.simple.fair.




Privacy                                                                       Financial Counselling Services
AGEST handles your personal information in accordance with a set of           (Republished with permission: www.fido.asic.gov.au)
National Privacy Principles. AGEST's privacy policy is available in our PDS
                                                                              Financial counselling services help people from a wide range of
and on our website, www.agest.com.au, or you can call us for a copy on
                                                                              backgrounds for free and in confidence. They can help you manage a
1300 724 378.
                                                                              short-term crisis and plan to prevent a future one.
                                                                              Financial counsellors help their clients remain independent and take full
                                                                              control of their own financial affairs. Counsellors can:
Eligible Commonwealth Government Income Support                                 ► help you organise your financial information, design a personal budget
Payments                                                                          and suggest ways to change and improve your financial situation;
AGEST understands that the payments listed below are eligible income            ► assess your eligibility for Government assistance;
support payments, however you should contact the relevant department to
ascertain whether a payment you are receiving is an eligible payment.           ► negotiate with your creditors;

Eligible Centrelink payments include:                                           ► explain debt recovery procedures, bankruptcy and other alternatives;

  ► widow allowance                                                             ► refer you to other services, for example, gambling, family support,
                                                                                  personal counselling or community legal aid.
  ► newstart allowance
                                                                              Typical problems that counsellors can assist with include:
  ► sickness benefit
                                                                                ► financial over-commitment – having more debt than you can deal
  ► partner allowance                                                             with;
  ► mature age allowance (granted after 1 July 1996)                            ► threatening letters, harassment by debt collectors;
  ► parenting allowance (other than parenting allowance paid at the basic       ► debt recovery through the Courts;
    rate independently of the spouses’ income)
                                                                                ► house eviction, disconnection of gas, electricity, phone etc;
  ► youth allowance to a person who is NOT undertaking full time study
                                                                                ► uninsured car accidents, taxation debts and unpaid fines.
  ► age pension
  ► disability support payment
  ► wife pension                                                              Financial Counselling Organisations
  ► carer pension                                                             AUSTRALIAN CAPITAL TERRITORY
  ► sole parent pension                                                         ► Care Financial Counselling Service - 02 6257 1788
  ► mature age partner allowance                                              NEW SOUTH WALES
  ► bereavement allowance                                                       ► NSW Financial Counsellors Association - 1800 888 079

  ► widow B pension                                                             ► Credit Helpline - 1800 808 488

  ► disability wage supplement                                                NORTHERN TERRITORY

  ► special needs pension                                                       ► Anglicare Northern Territory Financial Counselling
                                                                                  Service - 08 8948 2700 or 08 8985 0000
  ► mature age allowance (granted prior to 1 July 1996)
                                                                              QUEENSLAND
Centrelink can be contacted on 132 850 or 132 300.
                                                                                ► Lifeline Brisbane Financial Counselling Service - 07 3250 1912
                                                                              SOUTH AUSTRALIA
Eligible Department of Veteran’s Affairs (DVA) Service payments
include                                                                         ► Uniting Care Wesley Adelaide – 08 8202 5180
  ► age service pension                                                         ► Northern Community Legal Service - 08 8281 6911
  ► invalidity service pension                                                  ► Department of Family & Youth Services - 08 8226 7000
  ► partner service pension                                                   TASMANIA
  ► carer service pension                                                       ► Anglicare Financial Counselling Service - 03 6234 3510
  ► An income support supplement paid by DVA                                    ► Consumer Credit Solicitor at Hobart Community Legal Service - 03
                                                                                  6223 2500 or 1800 232 500
DVA can be contacted on 1300 134 606.
                                                                              VICTORIA
Drought Relief
                                                                                ► Financial and Consumer Rights Council - 03 9663 2000
  ► Drought relief payment under the Farm Household Support Act 1992
                                                                                ► Credit Helpline - 03 9602 3800
  ► Exceptional Circumstances Relief Payment under the Farm Household
    Support Act 1992 Community Development Employment Project                 WESTERN AUSTRALIA
    Scheme                                                                      ► Financial Counsellors Resource Project - 08 9221 9411
  ► Payment of Salary and wages made under the Community                        ► Consumer Credit Legal Service - 08 9481 7665
    Development Employment Projects Scheme

Payments NOT included as eligible payments
  ► parenting allowance paid at the basic rate independently of the
    spouse’s income
  ► family payments (formerly known as Family Allowance payments)
  ► Austudy/Abstudy
Benefit Application -
Financial Hardship                                                                                               straightfor ward.simple.fair.



 1. Your personal details                                                      2. Your Tax File Number (TFN)
                                                                               I have read the information on this form about my Tax File Number.
 Membership Number
                                                                               (please tick)

                                                                                     I choose to provide my TFN - it is
 Title (please tick)
                                                                                     I choose not to provide my TFN
       Miss            Ms      Mrs        Mr        Dr

 First name(s)                                                                       I have already provided my TFN to AGEST for this member account.


                                                                               3. Payment Details
 Family name                                                                   How much of your account balance do you believe that you need to
                                                                               relieve your financial hardship?
                                                                               Note: The Government only allows a single lump sum payment in any 12
 Date of birth                       Gender                                    month period (maximum $10,000). Special rules apply to some members
                                                                               who have reached their preservation age (currently 55) plus 39 weeks.
                                            F       M
                                                                                     Full Balance
 Telephone numbers
 Home                                Work
                                                                                                        Please tick one:       Gross         Net
 (     )                             (    )
                                                                                     Other amount:

 Mobile
                                                                                                        $                              .
                                                                               Payment Method

 Home Address (by law AGEST requires this to authorise a payment)                   Please send a cheque to the address I have noted on this form

                                                                                    Please transfer this payment electronically to my bank account
                                                                                    as follows:

                                                                               Bank/Financial Institution Name
 Suburb/Town



 State/Territory        Postcode
                                                                               Bank Address

 Mailing Address (if different to Home Address)



                                                                               Suburb/Town

 Suburb/Town
                                                                               State/Territory      Postcode

 State/Territory        Postcode
                                                                               Name(s) in which account is held

 Email Address (work or home)



                                                                               BSB Number

 Name of the employer who last contributed to AGEST for you (if any)

                                                                               Account Number



 Date you finished work with that employer (if applicable)                     Please note that if our electronic payment to the above account is
                                                                               unsuccessful, we will draw a cheque payable to you and send it to the
                                                                               address you noted on this form.



GFH                                                                    55529/01072007
                                                                       55529 / 25052009
                                                                                                                                           Page 1 of 4
Benefit Application -
Financial Hardship                                                                                                                                                                                             Page 2 of 4




4. Investment Choice                                                         Details of your financial hardship
If you have previously chosen to invest your AGEST account balance in        The space provided below is for you to detail your situation and provide
more than one investment option, you should complete this section to         reasons why you consider you are unable to meet reasonable and
indicate from which investment options this payment should be withdrawn.     immediate family living expenses.

If you do not complete this section, your payment will be withdrawn          Set out the causes of your financial hardship and how the money will be
from your investment options in proportion to the balance of each            used if released by AGEST. If your payment is requested to pay specific
investment option at the time of withdrawal.                                 bills, please write the specific amounts involved.
                                                                             Add any additional information you wish to provide in support of your
 Pre-Mixed Options                                                           application. If you need more room, please attach another page.

 Growth                            $                            .            ............................................................................................................................................................


                                                                .
                                                                             ............................................................................................................................................................
 Balanced                          $
                                                                             ............................................................................................................................................................
 Moderate                          $                            .            ............................................................................................................................................................

 Stable                            $                            .            ............................................................................................................................................................

                                                                             ............................................................................................................................................................
 Conservative                      $                            .            ............................................................................................................................................................

 MultiStrategy                     $                            .            ............................................................................................................................................................

 Single-Sector Options                                                       ............................................................................................................................................................

 Australian Shares                 $                            .            ............................................................................................................................................................


                                                                .
 International Shares                                                        ............................................................................................................................................................
                                   $
 (hedged)
                                                                             ............................................................................................................................................................
 International Shares
 (Unhedged)
                                   $                            .            ............................................................................................................................................................

 Listed Property                   $                            .            ............................................................................................................................................................

                                                                             ............................................................................................................................................................
 Fixed Interest                    $                            .            ............................................................................................................................................................

 Cash                              $                            .            ............................................................................................................................................................

                                                                             ............................................................................................................................................................

                                                                             ............................................................................................................................................................
5. General Information
                                                                             ............................................................................................................................................................
List the number of your financial dependants
(this includes your spouse and any children)                                 ............................................................................................................................................................

List the ages of your financial dependants
                                                                             6. Details of assets to which you currently have access
Are you currently employed?                    Yes         No
                                                                             If you have any financial assets, please complete this section. Write the
Do you currently have a spouse?                                              amounts you can access from
                                               Yes         No

Is your spouse?         employed       self-employed        unemployed         Bank Accounts                                                     $                                                                   .
Have you or your spouse received (or are entitled to receive) a redundancy
package or workers compensation lump sum payment?                              Share Market (current value)                                      $                                                                   .
     Yes           No
If yes, please write the amount received and when, or the amount you or
                                                                               Other Superannuation                                              $                                                                   .
your spouse expect to receive and when.
                                                                               Other assets or investments                                       $                                                                   .
                                   $                            .
Amount                                                                         Real Estate (other than the
                                                                               principal family home)
                                                                                                                                                 $                                                                   .
Date received/expected
                                                                               TOTAL                                                             $                                                                   .
Benefit Application -
Financial Hardship                                                                                                                         Page 3 of 4




7. Income and Expenses
This section enables AGEST to compare your income to your expenses. Consideration is given to your ability to meet your regular expenses and to any
outstanding amounts which are due and payable now.

Income

 Current total NET         Commonwealth Income Support                      Other Benefits                         Other income
 fortnightly income        Payments                                         (eg family allowance, child support)
            Your income
                           $                                   .            $                             .        $                           .
         Spouse income
                           $                                   .            $                             .        $                           .
      Dependants income
                           $                                   .            $                             .        $                           .
        TOTAL INCOME
                           $                                   .            $                             .        $                           .
Expenses

 Note: only the minimum monthly payment on credit cards and                 Regular expenses                       Arrears
 loans as well as any arrears are considered immediately due                (expenses per fortnight)               (due and payable now or overdue)
 and payable
                                                          Rent / Board
                                                                            $                              .       $                           .
                                              Home loan repayments
                                                                            $                              .       $                           .
                                           Personal loan repayments
                                                                            $                              .       $                           .
                                              Credit card repayments
                                                                            $                              .       $                           .
                                          Food and household items
                                                                            $                              .       $                           .
                                      Utilities (electricity, gas, phone)
                                                                            $                              .       $                           .
                Car running costs (fuel, registration, insurance, loan)
                                                                            $                              .       $                           .
                                          Municipal and Water Rates
                                                                            $                              .       $                           .
                                       Insurance (house, health, life)
                                                                            $                              .       $                           .
                                                             Education
                                                                            $                              .       $                           .
                                                  Medical and Dental
                                                                            $                              .       $                           .
 Other Expenses
 1.
                                                                            $                              .       $                           .
 2.
                                                                            $                              .       $                           .
 3.
                                                                            $                              .       $                           .
 4.
                                                                            $                              .       $                           .
 5.
                                                                            $                              .       $                           .
 TOTAL EXPENSES
                                                                            $                              .       $                           .
Benefit Application -
Financial Hardship                                                                                                                                                                                                                Page 4 of 4




8. Statutory Declaration                                                                                                                                           9. Authorisation
One of the following people should witness this document:                                                                                                          By signing this form, I am making the following statements:
A Justice of the Peace (JP) or bail justice; a barrister and solicitor of                                                                                            ► I declare I have fully read this form and the information completed is
the Supreme Court; a member of the police force; a councillor of a                                                                                                     true and correct.
municipality; a registered medical practitioner; a dentist; a veterinary
                                                                                                                                                                     ► I discharge the Trustee of AGEST from all further liability in respect of
practitioner; a pharmacist; the branch manager of a bank; a minister of
                                                                                                                                                                       the benefits paid and transferred.
religion; a teacher; a person accredited as a chartered accountant; or a
certified practicing accountant.                                                                                                                                     ► I authorise AGEST to deduct the appropriate rate of tax (if any) from
                                                                                                                                                                       my benefit.
                                                                                                                                                                     ► If I have current insurance cover, I understand that such cover for
(1) Insert your name, address and occupation
                                                                                                                                                                       death, total and permanent disablement and income protection
                                                                                                                                                                       benefits (if applicable) will cease for any event occurring on or after
    I, ...................................................................................................................................................of           the date that my full account balance is paid out of the fund.
                                                                                                                                                                     ► I authorise AGEST to pay or transfer a benefit as instructed on this
       ........................................................................................................................................................        form.
do solemnly and sincerely declare that the information provided by me in                                                                                           Signature
this Application is true and correct.
> I also declare that I agree to all the statements in Part 9 (see next
     column) of this application.
> I also declare that I am unable to meet my reasonable and immediate
     family living expenses and that I do not have any assets (apart from my                                                                                       Date
     home) which could (reasonably and realistically speaking) be used or
     sold to cover this gap.
> I also declare that the amount I am requesting to be released is
     necessary to meet these reasonable and immediate family expenses.                                                                                             Please send this form to:
I make this solemn declaration by virtue of the Statutory Declaration Act                                                                                          AGEST Administration
1959 as amended and subject to the penalties provided in that Act for the                                                                                          Locked Bag 20
making of false statements in the statutory declaration, conscientiously                                                                                           Wollongong NSW 2500
believing the statements contained in the declaration to be true in every
particular.

(2) Your signature

................................................................................................................................................................

Declared at .....................................................................................................................................

................................................................................................................................................................

on (Date)...........................................................................................................................................

before me,.......................................................................................................................................

(3) Signature of person before whom the declaration is made


................................................................................................................................................................


(4) Here insert printed name, qualifications and address of person
before whom the declaration is made.


................................................................................................................................................................


Note: A person who wilfully makes a false statement in a statutory
declaration under the Statutory Declaration Act 1959 as amended is
guilty of an offence against this Act the punishment for which is a fine not
exceeding $200 or imprisonment for a term not exceeding 6 months or
both if the offence is prosecuted summarily, or imprisonment for a term not
exceeding four years if the offence is prosecuted upon indictment.

								
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