Declared at ________________________ …………………………………………….. in the State of Victoria Signature of person making this declaration on the ________ day of ______________, (to be signed in front of an authorised witness) 20___ Before me ………………………………………. …………………………………………………… Signature of authorised witness Title of authorised witness pursuant to s.107A of the Evidence (Miscellaneous Provisions) Act 1958 (Vic) ______________________________________ Name of authorised witness ______________________________________ ______________________________________
Declared at ________________________ in the State of Victoria on the ________ day of ______________, 20___ …………………………………………….. Signature of person making this declaration (to be signed in front of an authorised witness) Before me ………………………………………. Signature of authorised witness …………………………………………………… Title of authorised witness pursuant to s.107A of the Evidence (Miscellaneous Provisions) Act 1958 (Vic) ______________________________________ Name of authorised witness ______________________________________ ______________________________________