Statutory Declaration PAYER - Community Law

Statutory
Declaration
When an application for a child support assessment is made
for a child who was born while the parents were not married,
the Child Support Agency (CSA) requires proof that the person
who is to pay the child support is the child’s parent.
PAYER
This form is to
be completed
by the parent
who is to make
child support
payments
One way of providing the proof is for you to declare in this
form that you are the parent of the child.
Commonwealth of Australia
Statutory Declaration
I, (full name of person
making declaration)
of (address)
Postcode
(occupation)
do solemnly and sincerely declare that I am the parent of the child/children named here.
Surname Given names Date of birth
/ /
/ /
/ /
/ /
/ /
And I make this solemn declaration by virtue of the Statutory Declarations Act 1959, and subject to the
penalties provided by that Act for the making of false statements in statutory declarations, conscientiously
believing the statements contained in this declaration to be true in every particular.
Signature of the person
making this declaration
Your signature must be witnessed by an
authorised person who then signs below. See
over the page for a list of authorised persons.
Declared at
on the day of 20
Before me
Signature of person before
whom the declaration is made
Title of person before whom
the declaration is made
CSA1685-06.04
Name of payee

Information Notes
Penalty for false statement
A person who deliberately makes a false statement in a statutory
declaration under the Statutory Declarations Act is guilty of an
offence under this Act. If the offence is prosecuted on indictment,
the penalty is imprisonment for a term not exceeding 4 years.
Your privacy
The information requested in this form is needed for child support
purposes and is required by child support law. Some information
may be passed to Centrelink, the Australian Taxation Office or to a
law enforcement officer.
Where to send this form
Please send this form to the address shown on CSA letters to you
or to the nearest CSA office.
Centrelink customers can lodge this form at a Centrelink Customer
Service Centre.
Child Support Agency Offices
NSW/ACT Sydney GPO Box 9815 Sydney 2001
VIC/TAS Melbourne GPO Box 9815 Melbourne 3001
QLD Brisbane GPO Box 9815 Brisbane 4001
SA Adelaide GPO Box 9815 Adelaide 5001
WA Perth PO Box 9815 Perth 6848
Need help to complete this form?
Telephone CSA on 131 272 (local call charge excluding mobile
and public phones).
For more information about CSA
• visit our Web site at www.csa.gov.au
• ask about our Fact Sheets.
If you have a complaint
• please contact us on 131 272 (local call charge excluding
mobile and public phones)
• if you are still not satisified call the Complaints Service
on 132 919.
Person before whom a statutory declaration
may be made
• Permanent employee of the Commonwealth Government with
5 years service;
• Justice of the Peace;
• Commissioner for Declarations;
• Member of the Commonwealth Parliament;
• Member of a State Parliament;
• Member of the Legislative Assembly of the Australian Capital
Territory;
• Member of the Legislative Assembly of the Northern Territory;
• Member of the Legislative Assembly of Norfolk Island;
• Judge;
• Magistrate;
• Master of a Court;
• Chief Executive Officer of a Federal Court;
• Registrar or Deputy Registrar of a Court;
• Clerk of a Court;
• Clerk of Petty Sessions;
• Sheriff;
• Sheriff’s Officer;
• Bailiff;
• Barrister;
• Solicitor;
• Registered Patent Attorney within the meaning of the Patents
Act 1990;
• Notary Public;
• Commissioner for Affidavits;
• Police Officer;
• Registered Medical Practitioner;
• Dentist;
• Pharmacist;
• Veterinary Surgeon;
• Minister of Religion designated as an authorised marriage
celebrant;
• Civil Marriage Celebrant;
• Holder of a Statutory Office;
• Alderman or Councillor of a Municipal or Shire Council;
• Senior Executive Service Officer of the Commonwealth Public
Service;
• Senior Executive Service Officer of a State Public Service;
• Senior Executive Service Officer of a Territory Public Service;
• Permanent Employee of a Territory Government with 5 years
service;
• Permanent Employee of a Local Government with 5 years service;
• Permanent Employee of a State Government with 5 years service;
• Officer of the Australian Navy or the Australian Air Force within
the meaning of the Defence Force Discipline Act 1982;
• Non-Commissioned Officer within the meaning of the Defence
Force Discipline Act 1982 with 5 years service;
• Warrant Officer within the meaning of the Defence Force
Discipline Act 1982 with 5 years service;
• Full-time Teacher at a school or tertiary education institution
with 5 years service;
• Registered Nurse or Enrolled Nurse with 5 years service;
• Bank Manager;
• Bank Officer with five years service;
• Building Society Officer with 5 years service;
• Credit Union Officer with 5 years service;
• Registered Member of the Institute of Chartered Accountants in
Australia, the Australian Society of Certified Practising
Accountants or the National Institute of Accountants;
• Postal Manager;
• Australian Postal Corporation Officer with 5 years service;
• Person before whom a statutory declaration may be made under
the law of the State or Territory in which the declaration is
made; or
• Australian Consular Officer or Australian Diplomatic Officer within
the meaning of the Consular Fees Act 1985.