File Number

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	ACT CIVIL AND ADMINISTRATIVE TRIBUNAL

STATUTORY DECLARATION
		
	For use with Guardianship and Management of Property Applications		

This declaration relates to the application to appoint a guardian or manager for: 

________________________________________________________________
                                               (Name of person)

I, _______________________________________________________________
[Name, address and occupation of person making the declaration] 
______________________________________________________________________________
make the following declaration under the Statutory Declarations Act 1959:

1.	I have*/ have not been convicted or found guilty of an offence involving violence, fraud or dishonesty.
2.	I have*/ have not been refused appointment as a guardian or manager, or removed from office as a guardian or manager, either in the Australian Capital Territory or anywhere else.
3.	I am*/am not bankrupt.
4.	I am*/am not personally insolvent.
	* Cross out the words that do not apply to you. Give details here of any conviction, finding of guilt, removal from or refusal of appointment or bankruptcy or personal insolvency.

_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________

I understand that a person who intentionally makes a false statement in a statutory declaration is guilty of an offence under section 11 of the Statutory Declarations Act 1959, and I believe that the statements in this declaration are true in every particular.

_____________________________________________________________________
[Signature of person making the declaration]

Declared at_______________________________________  on the______ of_____________  
                               [place] 		                                    [day]          [month]  [year]

Before me,

_____________________________________________________________________
[Signature of person before whom the declaration is made]

_____________________________________________________________________                   
				[Full name in printed letters]       

___________________________________________________________________________________
 [qualification]

_____________________________________________________________________
[address of person before whom the declaration is made]

Note 1   A person who intentionally makes a false statement in a statutory declaration is guilty of an offence, the punishment for which is imprisonment for a term of 4 years — see section 11 of the Statutory Declarations Act 1959.
Note 2   Chapter 2 of the Criminal Code applies to all offences against the Statutory Declarations Act 1959 — see section 5A of the Statutory Declarations Act 1959.

List of People before whom a Statutory Declaration can be made:
Chiropractor	Dentist	Legal practitioner	
Medical practitioner	Nurse	Optometrist	
Patent attorney	Pharmacist	Physiotherapist	
Psychologist	Trade marks attorney	Veterinary surgeon	
Postal Manager	Bailiff	Magistrate	
Australian Consular Officer or Australian Diplomatic Officer (within the meaning of the Consular Fees Act 1955)	Finance company officer with 5 or more years of continuous service	Bank, building society or credit union officer with 5 or more continuous years of service 	
Chief executive officer of a Commonwealth court	Clerk of a court	Fellow of the National Tax Accountants’ Association	
Commissioner for Declarations	Judge of a court	Holder of a statutory office	
Commissioner for Affidavits	Justice of the Peace	Marriage celebrant	
Member of Chartered Secretaries Australia	Master of a court	Member of Engineers Australia, other than at the grade of student	
Sheriff’s officer 	Notary public	Sheriff	
Registrar, or Deputy Registrar, of a court	Police officer	Minister of religion registered under the Marriage Act 1961	
Member of the Association of Taxation and Management Accountants	Teacher employed on a full-time basis at a school or tertiary education institution	Senior Executive Service employee of the Commonwealth, a Commonwealth authority, a State or Territory, or a State or Territory authority	
Employee of the Australian Trade Commission authorised under paragraph 3 (d) of the Consular Fees Act 1955 who is exercising his or her function outside Australia	Employee of the Commonwealth authorised under paragraph 3 (c) of the Consular Fees Act 1955who is exercising his or her function outside Australia	Permanent employee of the Australian Postal Corporation with 5 or more years of continuous service who is employed in an office supplying postal services to the public	
Person before whom a statutory declaration may be made under the law of the State or Territory in which the declaration is made	Member of: the Parliament of the Commonwealth, a State, a Territory legislature, or a local government authority of a State or Territory	
Member of the Australasian Institute of Mining and Metallurgy	Member of the Institute of Chartered Accountants in Australia, the Australian Society of Certified Practising Accountants or the National Institute of Accountants	
Permanent employee of
	(a)	the Commonwealth or a Commonwealth authority; or
	(b)	a State or Territory or a State or Territory authority; or
	(c)	a local government authority;
with at least 5 years continuous service 	Member of the Australian Defence Force who is:
	(a) an officer; 
	(b)	a non-commissioned officer within the meaning of the Defence Force Discipline Act 1982 with at least 5 years continuous service; 
(c) a warrant officer within the meaning of that Act