Registration No.

DCU
Form 902

ACT GOVERNMENT
Civil Unions Act 2006
Registrar-General’s Office

DECLARATION OF A CIVIL UNION

PRIVACY COLLECTION STATEMENT (PRIVACY ACT 1988 (CTH)) 

PRIVACY NOTES
The Births, Deaths and Marriages Registration Act 1997 authorises the Registrar-General to collect the information required by this form for the establishment and maintenance of registers.  The Registrar-General prevents any unreasonable intrusion into a person’s privacy in accordance with the Privacy Act 1988 (Cth).  	

GENERAL INFORMATION
The ACT Births, Deaths and Marriages Regulation requires this form, together with the Civil Union Declaration to be forwarded to the ACT Registrar-General’s office by the civil union celebrant following the declaration of a civil union under the Civil Union Act 2006, for the purposes of registration.

A Civil Union was declared between the parties, particulars of whom are provided below:	

	PARTY 1	PARTY 2	
1.	Surname			
2.	Given Names			
3.	Usual Occupation			
4.	Usual place of residence 			
5.	Relationship status (for example, never validly married, widower, widow, divorced, party to a terminated civil union)			
6.	Birthplace 			
7.	Date of birth			
8.	Father’s name in full 			
9.	Mother’s maiden name in full 			

SIGNATURES OF PARTIES	

Signatures of Parties			
Witness Name in Full (Please print)			
Witness Signatures			
Qualification of Witness			
Dated			

CERTIFICATION BY THE CIVIL UNION CELEBRANT	

I,                                                                                                                     hereby certify that, on the date and at the place specified above, the civil union between the parties specified above was declared in accordance with the provisions of the Civil Unions Act 2006.	
Celebrant’s Signature			
Celebrant’s Name 			
Celebrant’s Number			
Dated			
DECLARATIONS BY PARTIES	

	PARTY 1	PARTY 2	

I,	
(full name, address and occupation of person making the declaration)

Declare that:

1.	I am a person who  	
(state Relationship status – ie. who has never been validly married, who is single, who is divorced or terminated a civil union))

2.	I believe there is no legal impediment to enter into a civil union with:

	
(insert the full name and address of the other party to the civil union)

in particular:

•	Neither of us is married to another person; and

•	Neither of us is in a prohibited relationship; and

•	Both of us are over the age of 18 or have attached consent from our parent/s and a Court Order in accordance with the Civil Unions Act 2006; and

•	There is no other circumstance that would be a legal impediment to the civil union.

I make this declaration under the Civil Unions Act 2006, and I believe the statements to be true in every particular.

I,	
(full name, address and occupation of person making the declaration)

Declare that:

1.	I am a person who  	
(state Relationship status – ie. who has never been validly married, who is single, who is divorced or terminated a civil union))

2.	I believe there is no legal impediment to enter into a civil union with:

	
(insert the full name and address of the other party to the civil union)

in particular:

•	Neither of us is married to another person; and

•	Neither of us is in a prohibited relationship; and

•	Both of us are over the age of 18 or have attached consent from our parent/s and a Court Order in accordance with the Civil Unions Act 2006; and

•	There is no other circumstance that would be a legal impediment to the civil union.

I make this declaration under the Civil Unions Act 2006, and I believe the statements to be true in every particular.
	
Signature of Person Making Declaration			
Declared at		Canberra, ACT on		200    .	
	Place where declaration made		Date of declaration		
Before me			
	Name of civil union celebrant	Civil union celebrant number	
Signature of Civil Union Celebrant