MPD
Form 205

ACT GOVERNMENT
Births, Deaths and Marriages Registration Act 1997
Registrar-General’s Office

MEDICAL PRACTITIONER’S DECLARATION IN SUPPORT OF CHANGE OF SEX

PRIVACY COLLECTION STATEMENT (PRIVACY ACT 1988 (C’WLTH))

PRIVACY NOTES

The Births, Deaths and Marriages Registration Act 1997 authorises the Registrar-General to collect the information required by this form in processing your application.  The Registrar-General prevents any unreasonable intrusion into a person’s privacy in accordance with the Privacy Act 1988 (C’wlth).  However, the Registrar-General provides identifiable information to law enforcement organisations and authorised organisations that have the legal authority to request information under prescribed circumstances.	

GENERAL INFORMATION

This form is to be completed by a medical practitioner in support of an application to alter a person’s birth registration to record a change of sex.  An application to record a change of sex on a person’s birth registration must be supported by 2 completed medical practitioner’s declarations in support of a change of sex.

Section 23 of the Births, Deaths and Marriages Registration Act 1997 defines sexual reassignment as a surgical procedure involving the alteration of a person’s reproductive organs that is carried out – 
•	for the purpose of assisting a person to be considered to be a member of the opposite sex; or
•	to correct or eliminate an ambiguity relating to the sex of a person.	

FEES CURRENT TO 30 JUNE 2007

The fee to lodge an application to alter the birth register to record a change of sex is $34.00.  If you wish to apply for a new birth certificate after the alteration is made please complete an application for certificate form.  The fee to apply for a new certificate is $34.00 and if the certificate is to be sent by mail, a further $5.00 registered person to person postage fee applies.	

CONTACT DETAILS

The Registrar-General’s Office is located in Allara House, corner of Allara Street and Constitution Avenue, Canberra City.  Our postal address is PO Box 225, Civic Square ACT 2608.  Our office hours are 8:30am to 4:30pm Monday to Friday.  You may also download forms and information from our website at www.rgo.act.gov.au or contact this office on (02) 6207 0460.	

SIGNATURES AND WITNESSES TO SIGNATURES

This form must be signed by the medical practitioner and witnessed by a person who is authorised under the Statutory Declarations Act 1959.	

Telephone Interpreter Services	

If English is not your first language, and you need help with this form, please telephone 131 450 for assistance 24 hours a day.

Registration No

MPD
Form 205

ACT GOVERNMENT
Births, Deaths and Marriages Registration Act 1997
Registrar-General’s Office

MEDICAL PRACTITIONER’S DECLARATION IN SUPPORT OF CHANGE OF SEX

DETAILS OF THE PERSON WHOSE BIRTH REGISTRATION IS TO BE ALTERED	
Surname		Given names	
     		     	
Date of birth		Date sexual reassignment surgery performed	
     		     	
Sex recorded on original birth registration		Sex to be recorded on altered birth registration	
     		     	

MEDICAL PRACTITIONER’S DETAILS	
Surname		Given names	
     		     	
Surgery address		Postal address if different from surgery	
     		     	
			
	Postcode			Postcode	
Telephone number during business hours		Medical registration number	
     		     	

DECLARATION BY MEDICAL PRACTITIONER	
I, 	                                                                                                        being a (occupation)	
of (address)		Postcode	
hereby verify that the applicant named above has undergone sexual reassignment surgery as defined in section 23 of the Births, Deaths and Marriages Registration Act 1997, and that I have verified the applicant’s identity from documents produced to me, and solemnly and sincerely declare that the statements made above are true and correct by virtue of the Statutory Declarations Act 1959 and are subject to penalties provided by that Act for making false statements.	
Declared at (suburb/town)		State/Territory	
     		     	
Medical practitioner’s signature	Dated on	
     		     	
Before me (signature of witness)		Qualification of witness (JP, Solicitor, Police Officer or BDM Staff)	
     		     	
Telephone contact of witness		Full name of witness	
     		     	
Address of witness