Statutory declaration, Mia Calloway, lost bond receipt

Statutory declaration template in the correct Victorian form

A statutory declaration is only valid if it uses the right form for its purpose, sets out the facts in numbered paragraphs and is signed in front of an authorised witness. This one page example is a Melbourne renter declaring how she paid a $2,280 bond in cash and lost the receipt, laid out the way the Victorian form under the Oaths and Affirmations Act 2018 requires.

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Statutory declaration

I, Mia Calloway, of 7/41 Station Street, Footscray VIC 3011, retail assistant, make the following statutory declaration under the Oaths and Affirmations Act 2018:

1.
I rent 7/41 Station Street, Footscray under a residential rental agreement that began on Saturday 1 March 2025. It was arranged by Lintelby Real Estate, 12 Barkly Street, Footscray.
2.
On Monday 24 February 2025 I paid a bond of $2,280, equal to four weeks rent at $570 a week, in cash at the Lintelby Real Estate office.
3.
A staff member I knew as Dane gave me a handwritten receipt numbered 0457 for $2,280. I did not receive a bond lodgement form to sign.
4.
I kept the receipt in a folder of rental papers that was lost when I moved boxes into storage in August 2026. I have searched for it without success.
5.
On Monday 21 September 2026 I searched the Residential Tenancies Bond Authority online service and found no bond recorded for this agreement.
6.
My bank statement for February 2025 shows a cash withdrawal of $2,300 at the Footscray branch on 24 February 2025, the same day I paid the bond.

I declare that the contents of this statutory declaration are true and correct and I make it knowing that making a statutory declaration that I know to be untrue is an offence.

Declared at Footscray in the state of Victoria.

Person making the declaration
Name:
Mia Calloway
Date:

I am an authorised statutory declaration witness and I sign this document in the presence of the person making the declaration.

Authorised witness
Name:
Rohan Desai
Capacity:
Pharmacist
Address:
88 Nicholson St, Footscray
Date:
Warning
Making a statutory declaration you know to be untrue is a criminal offence in Victoria, with a fine of up to 600 penalty units, imprisonment for up to 5 years, or both. Sign only in front of the witness.

Section by section

What each section is for, so you can keep the ones you need and drop the rest.

Heading and declarant
The declarant's name, address and occupation, and the Act it is made under.
Numbered facts
Six paragraphs on the tenancy, the cash bond, the receipt, its loss, the bond search and the bank withdrawal.
Declaration sentence
The prescribed closing words about truth and the offence of a false declaration.
Signatures
Declarant and authorised witness side by side.
Witness qualification line
The witness confirms they are authorised and saw the declarant sign.
Warning
The penalty for a false declaration.

How to adapt this document

First, for a Commonwealth purpose, such as proving identity to a federal agency, keep the numbered facts but replace the opening and closing words with the Commonwealth form's wording and its list of witnesses. Second, for a statutory declaration supporting an insurance claim, list each item lost or damaged as its own paragraph with the date and value, so the insurer can check them one by one. Third, if the facts are long, keep each paragraph to one event and add pages rather than merging events, because the declaration is easier to rely on when every claim stands alone.

Which law the terms follow

This declaration is made in Victoria under the Oaths and Affirmations Act 2018, which sets the form, the closing words and the list of authorised witnesses in section 30. The bond it concerns is a Victorian matter handled by the Residential Tenancies Bond Authority. A declaration for a federal purpose follows the Statutory Declarations Act 1959 instead, and the other states each have their own form, so the jurisdiction of the receiving body decides which one you use.

What makes this document work

Each fact is one numbered paragraph

Six paragraphs run in time order: the agreement from 1 March 2025, the $2,280 paid in cash on 24 February, receipt 0457, the folder lost in August 2026, the empty bond search on 21 September, and a $2,300 withdrawal the same day as the payment. Anyone checking the declaration can test each fact on its own.

The wording follows the state form

The opening line names the Oaths and Affirmations Act 2018, and the closing sentence is the one the Victorian form prescribes: true and correct, made knowing that an untrue declaration is an offence. Using the form's own words is what makes a declaration acceptable to the body receiving it.

The witness says who they are

The witness block carries the qualification line from the form and prints the witness's name, capacity and address, here a pharmacist, one of the occupations allowed to witness a Victorian declaration. A declaration whose witness cannot be identified is the first thing a tribunal or agency will query.

Questions people ask

Which statutory declaration form should I use?

Use the form for the law the declaration is for. A Commonwealth matter, such as a federal agency or a Commonwealth benefit, needs the Commonwealth form under the Statutory Declarations Act 1959. A state matter, like a Victorian rental bond, needs that state's form. If the organisation asking supplies its own form, use theirs.

Who can witness a statutory declaration in Victoria?

A long list of people under section 30 of the Oaths and Affirmations Act 2018, including Justices of the Peace, police officers, lawyers, pharmacists, nurses, doctors, accountants with a recognised body, and bank officers with five years of service. The witness must see you sign and print their name, capacity and address, as this one does.

Can I attach documents to a statutory declaration?

Yes, but in Victoria each attachment needs an exhibit certificate, signed by you and the witness, identifying it as the document the declaration refers to. To keep this example to one page, the bank withdrawal is described in paragraph 6 rather than attached. If you attach a copy, complete the certificate with the witness at the same time.

Do I have to say anything out loud?

Yes. The Victorian form asks the declarant to say aloud, in front of the witness, that the contents are true and correct, using their name and address. It is a short sentence, and the witness will usually prompt you. Do not sign until you are with the witness, in person or through the online process Victoria now allows.

What happens if a statutory declaration is false?

Making a statutory declaration you know to be untrue is a criminal offence. In Victoria the maximum penalty is 600 penalty units, five years imprisonment, or both, which is why the warning sits at the foot of this one. If you are unsure of a fact, say so in the paragraph rather than state it as certain.

Can a statutory declaration replace a lost receipt?

It can be accepted as evidence of a payment, but the body deciding the dispute weighs it against other evidence. That is why this declaration adds a bank withdrawal on the same day and a bond search result. A declaration backed by independent records is far stronger than one that rests on memory alone.

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Sources

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