BIRTHS, DEATHS AND MARRIAGES
OFFICE OF REGULATORY SERVICES
Justice and Community Safety Directorate

DOCTOR OR PSYCHOLOGIST DECLARATION
 IN SUPPORT OF A CHANGE OF SEX		
Form 205 - MPD	

Births, Deaths and Marriages Registration Act 1997
Births, Deaths and Marriages Registration Regulations 1998		

IMPORTANT INFORMATION
This form is to be completed by a doctor or psychologist in support of an application to alter a person’s birth registration to record a change of sex. 

A psychologist is a person registered under the Health Practitioner Regulation National Law (ACT) to practice in the psychology profession (other than as a student).
The declaration must certify that the person has received appropriate clinical treatment for alteration of the person’s sex, or that they are an intersex person.

There is no fee to lodge this declaration in support of a change of sex, however a fee does apply for the lodgment of an application to alter the birth register to record a change of sex.
	
PRIVACY INFORMATION
The Births, Deaths and Marriages registration Act 1997 authorises the Registrar-General to collect the information required by this form.  The Registrar-General prevents any unreasonable intrusion into a person’s privacy in accordance with the Privacy Act 1988 (C’wlth). The Registrar-General may provide identifiable information to law enforcement organisations and authorised organisations that have legal authority to request information under prescribed circumstances. Documents provided as proof of identity may have their authenticity verified through Certificate Validation System (CVS) and the National Document Verification System (DVS). Documents issued by this office may also be verified by external agencies using CVS and/or DVS.
	
CONTACT INFORMATION	
Send completed forms to the Office of Regulatory Services:	GPO Box 158, Canberra ACT 2601	
Lodge in person at the Office of Regulatory Services:	255 Canberra Avenue, Fyshwick ACT 2609	
Office Hours:	9:00am to 4:30pm Monday to Friday	
General enquiries telephone number:	(02) 6207 3000	
Website address:	www.ors.act.gov.au 
	
INSTRUCTIONS FOR COMPLETION
•	If completing this form by hand please print clearly and use a blue or black pen only.
•	This office will not accept lodgement of this form if it is not completed in full.
•	Any alteration to information provided on this form must be struck through with a blue or black pen and substitute information must be clear and all parties must sign in the margin. Do not use white out.
•	If lodging the application in person, you must supply original identification documents.
•	If lodging the application by post, you must have all identification documents certified as true copies of the originals by a Justice of the Peace, Solicitor or Police Officer.
•	If lodging the application by post all signatures must be witnessed by a Justice of the Peace, Solicitor or Police Officer.

If you require further information or need advice, a language assistance service is available by phoning the
Translating and Interpreting Service (TIS) on 13 14 50.

	BIRTHS, DEATHS AND MARRIAGES
OFFICE OF REGULATORY SERVICES
Justice and Community Safety Directorate

DOCTOR OR PSYCHOLOGIST DECLARATION
 IN SUPPORT OF A CHANGE OF SEX 		
Form 205 - MPD	

Births, Deaths and Marriages Registration Act 1997
Births, Deaths and Marriages Registration Regulation 1998		

Registration Number
(Office use only)			Date received 
(Office use only)	/                    /	

DETAILS OF PERSON WHOSE BIRTH REGISTRATION IS TO BE ALTERED	
Current Surname	Current Given Name(s)	
		
Surname at Time of Birth	Given Name(s) at Time of Birth	
		
Date of Birth	Sex at Time of Birth	Place of Birth (in the ACT)	
/                /	 Male        Female
Unspecified/indeterminate/intersex   		

DETAILS OF CLINICAL TREATMENT 	
Dates of clinical treatment	Sex resulting from clinical treatment  	
_____/_____/_____ - _____/_____/_____	 Male    Female    Unspecified/indeterminate/intersex   

DETAILS OF DOCTOR OR PSYCHOLOGIST	
Surname	Given Names	
		
Telephone Number During Business Hours	Medical Registration Number	
		
Current Postal Address 	
	
	Postcode	

DECLARATION BY DOCTOR OR PSYCHOLOGIST (tick the appropriate boxes)	
I, (full name)	being a (occupation) 	
of (address)	
make the following declaration under the Statutory Declarations Act 1959:
 I hereby verify that the applicant named above has undergone appropriate clinical treatment for alteration of the person’s sex, and that I have verified the applicant’s identity from documents produced to me.
 I hereby verify that the applicant named above is an intersex person and that I have verified the applicant’s identity from documents produced to me.
 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.	
Signed	Declared at (place) 	on (date) 	
Before me, (signature of witness)	Full Name of Witness	
Qualification of Witness (Eg: Justice of the Peace, Solicitor, Police Officer or BDM Staff)	
Address of Witness