Instructions for completing a statutory declaration
Please complete the following form using the notes in the left-hand margin for guidance. More guidance on
making statutory declarations can be found at [Link].
When making the statutory declaration the declarant must say aloud:
I, [full name of person making declaration] of [address], declare that the contents of this statutory declaration are true
and correct.
Statutory Declaration
I,
Insert the name, address
and occupation (or
alternatively, unemployed
or retired or child) of
person making the
statutory declaration. make the following statutory declaration under the Oaths and Affirmations
Act 2018:
1. Since the passing of my uncle in late august 2025, I have been experiencing
significant stress and difficulty managing my studies and general wellbeing. I
Set out matter declared to obtained a medical certificate at that time to cover my initial extension.
in numbered paragraphs. 2. In addition, this week my parents travelled overseas and I have been responsible
Add numbers as necessary. for managing the household and caring for my younger brother. Balancing these
responsibilities alongside full-time work and multiple university assignments has
been overwhelming.
3. I have been experiencing heightened stress and anxiety during this period, which
has affected my ability to complete academic work. I also have a previous history
of mental health difficulties, and these recent events have contributed to a
recurrence of symptoms that make it difficult to focus and maintain productivity.
4. On 5 September 2025, I consulted the doctor again who issued a medical
certificate for the period 5–8 September 2025 as she could see I wasn’t well. She
advised me to provide a statutory declaration to explain the broader circumstances
impacting my ability to study.
5. Due to these ongoing and compounding personal, medical, and family
responsibilities, I have been unable to complete my assignments by the current due
date of 5 September 2025.
6. I respectfully request special consideration and an extension until Friday, 12
September 2025, to enable me to finalise and submit the affected assignments.
I declare that the contents of this statutory declaration are true and
correct and I make it knowing that making a statutory declaration that I
know to be untrue is an offence.
Signature of person
making the declaration
Declared at
Place (City, town or *in the state of Victoria
suburb)
on
Date
I am an authorised statutory declaration witness and I sign this document
Signature of authorised in the presence of the person making the declaration:
statutory declaration
witness
Date on
Name, capacity in which
authorised person has
authority to witness
statutory declaration, and A person authorised under section 30(2) of the Oaths and Affirmations Act
address (writing, typing or 2018 to witness the signing of a statutory declaration.
stamp)
I certify that I read this statutory declaration to [name of the person making
The witness must only sign the statutory declaration] at the time the statutory declaration was made.
this section if the person
making the statutory
declaration is illiterate,
blind or cognitively
impaired and the statutory
declaration is read to
them.
This section must be I certify that I have assisted [name of the declarant] by [insert assistance
signed by any person who provided, for example translating the document].
has assisted the person
making the statutory
declaration, for example Signed:
by translating the
document or reading it
aloud. If no assistance was
required, this section does
not need to be completed.
On:
Date
Name and address of
person providing
assistance
Name and address of person providing assistance:
