Approved form AF2002-180

made under the
Workers Compensation Rules 1938

Workers Compensation Rules 1938— Form 55
(see r 57 (10) and (12))

Declaration of identity by worker residing out of Australia
[Heading as in award or memorandum.]
I, A.B.			of			declare that I am the same person as A.B.				of			  described in the copy of the certificate of the medical referee in this matter, dated 				, now produced by me, and in the certificate of identity, dated 					    , now produced by me, and the same person as A.B.			of		  described in the certificate of 			declared by the said	 in my presence on the			day of			 , and now produced by me.
(Signed)
A.B.
Declared at 		        this			day of			  the certificates being at the same time produced,
Before me—
[Signature and description of person before whom the 
declaration is made.]

Endnotes
1	This form was originally in the Workers Compensation Rules 1938, schedule 1.  Under amendments made by the Legislation (Consequential Amendments) Act 2001, the form was omitted from the rules and became a form approved under the rules, rule 89 (see amdt 1.2805, amdt 1.2807).
2	This republication includes amendments made under the Legislation Act 2001, part 11.3 (Editorial changes).

©  Australian Capital Territory 2002