Registration No.

WTCU
Form 904

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

WITHDRAWAL OF TERMINATION 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
Persons wishing to terminate a civil union in accordance with the Civil Unions Act 2006 must lodge a termination notice in writing to the ACT Registrar-General of their intention to termination the civil union.  A civil union may also be terminated by a party (or both parties) under section 13 or a court order under section 14 of the Civil Unions Act.  

A termination of a civil union will take effect 12 months after the termination notice is lodged with the Registrar-General.  However, the termination notice may be withdrawn by lodging a ‘Withdrawal of Termination of a Civil Union’ with the Registrar-General by the party (or parties) who gave the notice before the termination period of 12 months expires.	

CIVIL UNION REGISTRATION NUMBER	DATE OF CIVIL UNION	
		
	PARTY 1	PARTY 2	
1.	Surname			
2.	Given Names			
3.	Usual place of residence 			
4.	Birthplace 			
5.	Date of birth			

SIGNATURES OF PARTIES	

Signatures of Parties			
Dated			

STATUTORY DECLARATION (only required if this notice is only given by one of the parties to the civil union.  The notice will be effective only if a copy has been served on the other party in accordance with Section 18 of the Civil Unions Act 2006).	

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

Declare that I have served a copy of this notice on the other party to this civil union being:

								On 						
(full name of other party)							(Date served)
I make this declaration under the Statutory Declarations Act 1959, and I believe the statements to be true in every particular.	
Signature of Person Making Declaration		
Declared at		Canberra, ACT on		2006.	
	Place where declaration made		Date of declaration		
Before me			
	Full Name of Witness	Signature of Witness	
Address of Witness		
Qualification of Witness