File Number:
GT        /      	ACT CIVIL AND ADMINISTRATIVE TRIBUNAL
STATEMENT OF PROPERTY- STATUTORY DECLARATION		
	For use in Guardianship and Management of Property matters		

Guardianship and Management of Property Act 1991

IN THE MATTER OF: 									
                                                        (Name of Protected Person)

STATUTORY DECLARATION

I, _______________________________________________________________
[Name, address and occupation of person making the declaration] 
______________________________________________________________________________
do solemnly and sincerely declare that the person’s income, assets and liabilities as at the date of this declaration is as set out on this form and any attachment to this form
DETAILS OF PROTECTED PERSON’S PROPERTY AFFAIRS
(If space on this form is insufficient, attach a sheet and sign at the foot of each attachment)
1.	INCOME
Source of income	Yearly amount	
Pension	$______________	
Employment	$______________	
Superannuation	$______________	
Income from investments	$______________	
Rent Received	$______________	
Other	$______________	
2.	ASSETS
Description of Assets			Estimated Value	
Bank Accounts				
Name of Bank	Branch	Account number		
__________________	____________________	___________________	$_____________	
__________________	____________________	___________________	$_____________	

Real Estate
Address of Property:_________________________________________

______________________________________________________		    $___________
Furniture (please attach inventory on separate sheet)	$____________	
Motor Vehicle	$____________	
Shares/Investments (please attach schedule on separate sheet)	$____________	
Personal effects (jewellery, antiques etc. please attach inventory on separate sheet)	$____________	
Debts due to Represented Person	$____________	
3.	LIABILITIES
	Unpaid Accounts
Name and Address of Lender	Type of Loan	Amount of Loan	
______________________________	___________________________	$________________	
______________________________	___________________________	$________________	
______________________________	___________________________	$________________	
Credit Cards (Name)	Limit	Amount owed	
________________________	__________________________	$________________	
________________________	__________________________	$________________	
________________________	__________________________	$________________	
Other liabilities (attach schedule if necessary)	Amount	
________________________________________________________	$________________	
________________________________________________________	$________________	
_________________________________________________________	$________________	

_____________________________________                                                                         
[Signature of person making the declaration]

Declared at_________________    on_______ of____________
[place] 	           [day] 	     [month]  [year]
Before me,

____________________________________

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]

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.

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.