any incident or injury suffered by me in connection with my service with the Australian Defence Force or Department of Defence. Signature: Full Name: Date: Important note: This is set out as a Statutory Declaration. A person who Reporting Abuse form intentionally makes a false statement in a Statutory Declaration is guilty of an offence, the punishment for which is imprisonment for a term of up to four years Section 11 Statutory – (Cth). Declarations Act 1959 Current driver’s licence Please attach a certified copy of Current concession card proof of your identity: of age’ card ‘Proof Note: You only need to provide one certified Employee identity card issued by an Australian copy of proof of your identity Refer to the last page of this form for details Government Authority of who may/how to certify documents Current passport identification page Senior’s card Other recognised proof of identity Comment: The Ombudsman acknowledges that in some circumstances you may not be able to provide proof of identity documentation because it does not exist or because you live in a remote or isolated area. In these circumstances you should have a referee complete this section: I (Referee’s full name) of (Referee’s address) have
any incident or injury suffered by me in connection with my service with the Australian Defence Force or Department of Defence. Signature: Full Name: Date: Important note: This Reporting Abuse form is set out as a Statutory Declaration. 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 up to four years – Section 11 Statutory Declarations Act 1959 (Cth). Please attach a certified copy of proof of your identity: Note: You only need to provide one certified copy of proof of your identity Refer to the last page of this form for details of who may/how to certify documents Current driver’s licence Current concession card ‘Proof of age’ card Employee identity card issued by an Australian Government Authority Current passport identification page Senior’s card Other recognised proof of identity Comment: The Ombudsman acknowledges that in some circumstances you may not be able to provide proof of identity documentation because it does not exist or because you live in a remote or isolated area. In these circumstances you should have a referee complete this section: I (Referee’s full name) of (Referee’s address) have
NEW-FINAL-Reporting-abuse-form-New-report-of-abuse.docx