ACS
Form 204

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

APPLICATION TO ALTER BIRTH REGISTER TO RECORD 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 can be used to apply to the Registrar-General for alteration of a person’s sex in the registration of the person’s birth if:
•	the person is at least 18 years of age; and
•	the person’s birth is registered in the ACT; and
•	the person has undergone sexual reassignment surgery; and
•	the person is not married.

This form may also be used by the parent/s or guardian/s of a child to apply for the alteration of a child’s sex in the registration of the child’s birth if the child’s birth is registered in the ACT and the child has undergone sexual reassignment surgery.  One parent may make application if only one parent is named in the child’s birth registration or if a parent is deceased, in which case a copy of the death certificate is required.  

The application must also be accompanied by two completed medical practitioner’s declarations verifying that the person has undergone sexual reassignment surgery and three forms of identification from the applicant/s.	

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 at 255 Canberra Avenue, Fyshwick ACT 2609.  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.	

WITNESSES TO SIGNATURES AND CERTIFIED COPIES OF DOCUMENTS

If you are lodging this application in person you must supply original identification documentation.  If sending your application by post you must have the identification documents certified as true copies of the original documents by a Justice of the Peace, Solicitor or Police Officer.  If you are lodging this application in person all signatures may be witnessed by Births, Deaths and Marriages staff within the Registrar-General’s Office.  If you are sending your application by post all signatures must be witnessed by a Justice of the Peace, Solicitor or Police Officer. 	

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

ACS
Form 204

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

APPLICATION TO ALTER BIRTH REGISTER TO RECORD CHANGE OF SEX

DETAILS OF THE PERSON WHOSE BIRTH REGISTRATION IS TO BE ALTERED	
Surname		Former surname if any	
     		     	
Given names		Former given names if any	
     		     	
Date of birth		Place of birth in ACT	
     		     	
Sex at time of birth		Date sexual reassignment surgery performed	
     		     	
Mother’s/Parent’s full name		Mother’s/Parent’s former full name if any	
     		     	
Father’s/Parent’s full name		Father’s/Parent’s former full name if any	
     		     	
If ever married 		If ever married how the marriage was terminated	
                                      Yes / No		     	
Current residential address		Postal address if different from residential	
     		     	
			
	Postcode			Postcode	
Telephone number during business hours		E-mail address	
     		     	

DECLARATION BY APPLICANT/PARENT/GUARDIAN	
I, 	                                                                                                        being a (occupation)	
of (address)		Postcode	
hereby apply to the Registrar-General to alter the information as described above and solemnly and sincerely declare that the statements made in this application 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	
     		     	
Applicant’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	
     	

DECLARATION BY PARENT/GUARDIAN IF REQUIRED	
I, 	                                                                                                        being a (occupation)	
of (address)		Postcode	
hereby apply to the Registrar-General to alter the information as described above and solemnly and sincerely declare that the statements made in this application 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	
     		     	
Applicant’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	
     	

PAYMENT DETAILS
If you are applying by mail and payment is by credit card please complete the details below.  If you are using another person’s credit card, the cardholder must also provide written consent and identification before the application will be processed.  Payment may be made by cash, credit card, EFTPOS, money order or cheque, all cheques and money orders should be made payable to the Registrar-General.  Applications paid by personal cheque will be held for 7-10 working days for the cheque to clear.	

 Mastercard	 Visa Card	Amount	$	
																						
Card Number																					Expiry Date 	   __ __ /  __ __	
	
Name of Cardholder		Signature of Cardholder