Sample Form - Statutory Declaration

Sample Statutory Declaration for a member to request a copy of the register of members of an association.

STATUTORY DECLARATION

Oaths, Affidavits and Statutory Declarations Act 2005

Request for a copy or extract of Association’s Register of Members (s54(3) or s56(2) of the Act)

I,

 

(name of person making declaration)

of

 

(address of person making declaration)

occupation

 

(occupation of person making declaration)

 

sincerely declare as follows:

  1. I am a current member of                         (insert incorporated association name) (Association).
  2. My request of                                (insert date of request) to obtain a copy or extract of the register of members of the Association is made for the purpose of                          (insert purpose of obtaining information), which is connected with the Association’s affairs.
  3. I declare that this purpose is connected with the affairs of the Association.
  4. I understand that it is a criminal offence to disclose information in the register of members for a purpose that is not directly connected with the affairs of the Association or that is not related to the administration of the Associations Incorporation Act 2015 (Unlawful Purposes).
  5. I will not disclose information obtained from the register for Unlawful Purposes.
  6. I understand that Unlawful Purposes include, but are not limited to, advertising for political, religious, charitable or commercial purposes.

This declaration is true and I know that it is an offence to make a declaration knowing that it is false in a material particular.

This declaration is made under the Oaths, Affidavits and Statutory Declarations Act 2005

At 

 

(place)

On

 

(date)

By

 

(signature of person making the declaration)
       

 

In the presence of:

 

(signature of authorised witness)

 

(name of authorised witness)

 

(qualification as such a witness)

Information about preparing and witnessing statutory declarations is available from www.courts.dotag.wa.gov.au.