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Revised 11/11 VP Form 755

STATUTORY DECLARATION

I,
of
in the State of Victoria, do solemnly and sincerely declare:

I acknowledge that this declaration is true and correct and I make it in the belief that a person making a false declaration
is liable to the penalties of perjury.
Signature Of Person
Making Declaration

Declared at in the State of Victoria on


Before me,
SIGNATURE

PRINT NAME

ADDRESS
Justice of the Peace or Bail Justice
Member of the Police Force
STATUS Person authorised under Section 107A(1) of the Evidence
(Miscellaneous Provisions) Act 1958 to witness the signing of a
Statutory Declaration

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