Statutory Declaration examples

These example Statutory Declarations show the information you should include in your Statutory Declaration when applying for parental leave.

A standard form Statutory Declaration is available on the Attorney-General's Department website.

Example 1: Birth mother

I, Jane Sanderson of 16 Wentworth Street, Wagga Wagga, Laboratory Manager, make the following declaration under the Statutory Declarations Act 1959:

  1. I am pregnant and have applied for parental leave for the period from 20 May 2018 to 17 February 2019, including primary carer leave. My baby is due on 5 June 2018;
  2. Throughout the period of primary carer leave I will be the primary carer for my child;
  3. I agree to notify the University if circumstances change in relation to primary care arrangements for my child during the period of paid leave;
  4. I will not undertake any paid work during maternity and primary carer leave.

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:

Place and date:

Signature of person before whom the declaration is made:

Example 2: Spouse/partner

I, Jeremy Lyons of 23 Underwood Street, Dubbo, Project Officer, make the following declaration under the Statutory Declarations Act 1959:

  1. My partner is pregnant and is due to give birth on 1 March 2018. She will be returning to work on 3 June 2018;
  2. I intend to take 2 weeks concurrent parental leave at the time of the baby’s birth and primary carer leave from 3 June to 30 September 2018;
  3. Throughout the period of primary carer leave I will be the primary carer for my child;
  4. I agree to notify the University if circumstances change in relation to primary care arrangements for my child during the period of primary carer leave;
  5. I will not undertake any paid work during primary carer leave.

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:

Place and date:

Signature of person before whom the declaration is made:

Example 3: Adopting parent

I, Anna Thompson of 7 Blacksmiths Close, Thurgoona, Senior Lecturer, make the following declaration under the Statutory Declarations Act 1959:

  1. My partner and I will be adopting a child and the expected date of placement is 8 April 2018;
  2. The child is not a child or step-child or either myself or my partner;
  3. At the time of placement, the child will not have lived with us for a continuous period of six months or more;
  4. I am intending to take primary carer leave from 8 April 2018 to 23 August 2018;
  5. Throughout the period of primary carer leave I will be the primary carer for my adopted child;
  6. I agree to notify the University if circumstances change in relation to primary care arrangements for my child during the period of paid leave;
  7. I will not undertake any paid work during primary carer leave.

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:

Place and date:

Signature of person before whom the declaration is made: