You are on page 1of 1


(1) Insert name,

address and
occupation of
person making the
(2) Name of the child
(3) Name of biological mother
(4) Name of biological father
(5) Name of birth mother
() !trike out "hiche#er is not
do solemnl$ and sincerel$ declare
% &he biological mother of
(herein after kno"n as 'the
child() is
% &he biological father of the child is
% &he birth mother of the child is
% &hat surrogac$ arrangements )*+*,)*+* N-&
used in relation to the child
% &hat artificial conception procedures )*+*,)*+* N-&
used in relation to the child
% &hat I ha#e not been e.cluded through a court of la" from ha#ing custod$ or legal guardianship of
the child
% &hat custod$ proceedings or court hearings in relation to custod$,guardianship of the child
/+*,/+* N-& () presentl$ ongoing or ha#e commenced.
I full$ understand the abo#e, or the abo#e has been full$ e.plained to me b$ another person or interpreter "ho full$
understands the abo#e, such that I full$ understand the abo#e.
I understand that an$ incorrect information ma$ result in refusal or cancellation of the /ustralian citi0enship of the child.
I make this solemn declaration b$ #irtue of the Indian Oaths Act 1969, and sub1ect to the penalties pro#ided b$ the la"
for the making of false statements in s"orn statements, conscientiousl$ belie#ing the statements contained in this
declaration to be true in e#er$ particular to the best of m$ kno"ledge and belief.
(2) !ignature of
person making the
(2) 3eponent
(5) !ignature of person
before "hom the
6.declaration is made.
(7) !ignature of person
before "hom the
declaration is made
1. (5).
2. (7).
/ffi. IN+28
stamp here
Witnessed and stamped by Notary Public
N-&* 9 / person "ho "ilfull$ makes a false statement in a s"orn statement under the INDIAN OATHS ACT 1969 is guilt$ of an offence
against that /ct.