Approved Form AF2010-99 approved by L Crebbin (General President) and B Stefaniak (Appeal President) on 29 October 2010 under section 117 of the ACT Civil and Administrative Tribunal Act 2008. This form will repeal the form AF2009-50

Authorised by the ACT Parliamentary Counsel—also accessible at www.legislation.act.gov.au

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.

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File Number /

ACT CIVIL AND ADMINISTRATIVE TRIBUNAL

STATUTORY DECLARATION

For use with Guardianship and Management of Property Applications

Approved Form AF2010-99 approved by L Crebbin (General President) and B Stefaniak (Appeal President) on 29 October 2010 under section 117 of the ACT Civil and Administrative Tribunal Act 2008. This form will repeal the form AF2009-50

Authorised by the ACT Parliamentary Counsel—also accessible at www.legislation.act.gov.au

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.

Approved Form AF2010-99 approved by L Crebbin (General President) and B Stefaniak (Appeal President) on 29 October 2010 under section 117 of the ACT Civil and Administrative Tribunal Act 2008. This form will repeal the form AF2009-50

Authorised by the ACT Parliamentary Counsel—also accessible at www.legislation.act.gov.au

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