S24 - Instruction for Change of Name of a Child by One Parent-Guardian

INSTRUCTION FOR CHANGE OF NAME OF A CHILD BY ONE PARENT/GUARDIAN

APPLICABLE TO CHILDREN WHO RESIDE IN THE TERRITORY,

OR WHOSE BIRTH IS REGISTERED IN THE TERRITORY

1.Parent or Guardian must complete and sign the form.

A birth certificate for the child must be sighted by our office prior to registration. If child was born in the Northern Territory and currently has a birth certificate, this certificate needs to be returned for cancellation/sighting.

Fees: $88.00 to be paid with lodgement of forms- ($44.00 for the registration fee and $44.00 for a certified copy of the Change of Name). Further copies of the name change are available at a cost of $44.00 each. Registered mail is $12.30 (or $16.10 for international registered mail). Clients can also collect the certificates as per addresses below*.

The parent/guardian may have their childs birth registration noted with the new name if they were born in Australia. When born interstate, the relevant state will be notified, but any further documentation and/or fees will need to be negotiated directly with that state by the applicant.

Evidence of identification of applicant MUST be sighted prior to change of name being processed. Drivers licence, medicare card, bank card, keycard or pension cards are some examples and if posting the application or not attending in person, the identification must be certified by a qualified person. e.g. Justice of the Peace or a Commissioner for Oaths.

Court Orders, Death Certificates, interstate birth certificatesother documents which are required to accompany the name change registration must be ORIGINALS. These documents will be returned to you after completion of the registration.

If the child was NOT born in the Northern Territory, proof of residency of the parent/guardian MUST accompany this application and evidence provided that the family have lived in the Northern Territory for not less than 3 months from current date. Telstra, Power & Water or Rent bills are examples of proof.

For NorthernTerritory births only, if a birth certificate in the NEW name is required, an additional $43.00 for each certificate is necessary.

If a person has registered a change of name with any Registry in Australia within a period of 12 months, any further applications for change of name at any Registry in Australia within that 12 month period will be refused, except with the consent of the Registrar upon consideration of the applicant’s reason for the change.

Reason for change of name. The reason for the change of name must be provided. The statement “Personal”, or similar statements, are NOT acceptable as a reason for applying to register a change of name.

OFFICES FOR LODGEMENT, REGISTRATION AND COLLECTION

DARWIN / PALMERSTON / ALICE SPRINGS
Nichols Place
Cnr Bennett & Cavenagh Streets / Palmerston Community Care Centre
Palmerston Health Precinct in Guard Street / GroundFloorCentrepointBuilding
Cnr Hartley Street & Gregory Terrace
Monday – Friday; 8am - 4pm
Phone: (08) 8999 6119 / Please call the office for opening hours
Phone: (08) 8999 6119 / Monday – Friday; 8am - 4pm
Phone: (08) 8951 5338
GPO Box 3021
DARWIN NT 0801 / Nil / P O Box 8043
ALICE SPRINGS NT 0871

PRIVACY STATEMENT

The Office of Births, Deaths & Marriages is collecting the information on a change of name form so that it can determine your eligibility to register the requested change of name and to prevent fraud. If all the information requested is not completed then the change of name may not be registered. The collection of the information is required by the Northern TerritoryBirths, Deaths and Marriages Registration Act.

The information is recorded and preserved in the Register of Changes of Name and in appropriate cases, may be accessed by government agencies, private organisations and members of the public in accordance with the Access Policy issued under the Act.

Failure to provide the information may result in incomplete registration entries and the non-issue of certificates. Your personal information provided in this form can be accessed by you on request. If you have any queries please contact the Deputy Registrar on (08) 8999 6119.

NORTHERN TERRITORY OFFICE OF BIRTHS, DEATHS & MARRIAGES

CHANGE OF NAME OF CHILD BY ONE PARENT/GUARDIAN - SECTION 24

NAME OF APPLICANT (parent/guardian)
NAME OF CHILD
CERTIFICATE IS TO BE  / COLLECTED
(ID required for sighting) / POSTED
( Additional $12.30 for secure postage)
Signature and Date on Collection: / POSTAL ADDRESS:
CONTACT PHONE NOS: / Home: / Work: / Mobile:
Reason for Name Change (see Note 10 on Instruction sheet)
How long has the child resided in the Northern Territory
(only necessary to complete if not born in the NT) / ______
Has the child’s name been changed within the last 12 months? / YES / NO
If the child was born interstate, do you wish to have the Birth Registration amended to show the new name? / YES / NO
Note: If the child was born interstate, the relevant state will be NOTIFIED automatically of the name change, however, if you have indicated that you do not want the birth entry to be noted the state will be advised of this.
You will need to liaise with the state where your child was born if you wish for your childs birth registration to be amended. This is not done automatically.
Visa / Bankcard / Mastercard
Card No: / ______/ Expiry Date: / _____ / ____
Card Holder’s Name: (BLOCK PRINT) / ______
Amount to be debited / $ / Signature: / ______

OFFICE USE ONLY

Change of Name Details / Birth Certificate Details
APP NO: / REG NO:
REG NO:

APPLICATION BY ONE PARENT OR GUARDIAN TO REGISTER THE CHANGE OF NAME OF A CHILD

PLEASE PRINT CLEARLY IN BLOCK LETTERS
WHITE OUT NOT TO BE USED
ANY CORRECTIONS MADE SHOULD BE INITIALED

OLD NAME

Child’s Given Name(s) / Sex of Child
Male □ Female □
Child’s Surname
Child’s Date of Birth / Child’s Place of Birth
Is this the child’s registered birth name?
Yes  No 
If not please state registered name : / If born in the Northern Territory do you wish the child’s birth certificate to be noted with the name change?
Yes  No 
NEW NAME
New GIVEN NAME(s) of Child / Current Residential Address of Child
New SURNAME of child
PARENT/GUARDIAN
Full Name of Parent/Guardian Changing Child’s Name / Residential Address of Parent/Guardian

I am the sole parent/guardian of the child, on my behalf as well as for and on behalf of the child, absolutely renounce and abandon the use of the child’s old name and assume the new name in its place and declare that I and the child will at all times, in all records, deeds and instruments, in all actions, suits and proceedings, in all dealings and transactions and upon all occasions use and sign the new name as the name of the child and authorise and request all persons to designate and address the child by the new name.

CIRCUMSTANCES RELATING TO CHANGE OF NAME BY ONE PARENT/GUARDIAN

(Please tick those applicable)

□ I am the sole parent named in the registration of the child’s birth (child’s birth certificate attached)

□ The other parent of the child is deceased and no other person has legal responsibilities towards the child

(copy of other parent’s death certificate attached).

□The other parent (or some other person) has custody or guardianship rights or the equivalent but would not object to the change of name (appropriate evidence, as required by the Registrar, is attached), OR

□The other parent (or some other person) has custody or guardianship rights or the equivalent and consents to the change of name as indicated below (this may include a new spouse of a parent whose name the child is taking).

□ The Court approves the proposed change of name (Court Order Attached).

□I, not being a parent of the child, am the guardian of the child. (Court Order attached or other proof of guardianship where the parents are dead, cannot be found or cannot exercise their parental responsibilities).

SIGNATURES

PARENT OR GUARDIAN
I certify that there are no prevailing court orders relating to the naming of the child and that to my knowledge and belief there are no other persons, apart from those named in this document, who would be required to consent to the change of name of the child.
SIGNATURE OF PARENT/GUARDIAN:  Date:
SIGNATURE OF WITNESS: FULL NAME OF WITNESS:
TELEPHONE NUMBER:
SIGNATURE OF GUARDIAN OR OTHER PERSON WITH AN INTEREST, REQUIRED TO CONSENT TO THE NAME CHANGE
I ______of______(full name) (insert address)
being the ______(guardian, person with an interest etc)
hereby consent to the change of name of the child
SIGNATURE OF GUARDIAN:  Date:
SIGNATURE OF WITNESS: FULL NAME OF WITNESS:
TELEPHONE NUMBER:
CHILD: / This section need not be completed if the child is unaware of the meaning and implication of his or her name.
This section must be completed if the child is over the age of 14 years.
I, the above child, consent to the change of my name as described above
SIGNATURE OF CHILD:  Date:
SIGNATURE OF WITNESS: FULL NAME OF WITNESS:
TELEPHONE NUMBER:

OFFICE USE ONLY

MEMORANDUM

The within Change of Name numbered was registered at DarwinNT the

day of 20 .

Deputy Registrar of Births, Deaths & Marriages / /20

STATUTORY DECLARATION

(1) Here insert name and address of person making the declaration / I, ………………………………………………………………………………………………… (please insert full name and address)
do solemnly and sincerely declare (2)
(2) Here insert the matter declared to, either directly following the word “declare” or, if the matter is lengthy insert the words “as follows” and thereafter set out the matter in numbered paragraphs / - That I have previously received a birth certificate for …………………………………..
- That I am unable to produce this birth certificate for the following reasons:
……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
- That I will return any birth certificates received prior to this change of name for cancellation if located in the future.
......
And I make this solemn declaration by virtue of the Oaths Act and conscientiously believing the statements contained in this declaration to be true in every particular.
Declared at Darwin the ...... day of ...... 20
(3) Signatures of the persons making the declaration / (3)
...... ………...... ………....
(please sign here)
(4) Signature of the person before whom the declaration is made / (4) .
...... ………...... ………......
Before me: / (witness to sign here)
(5) Here insert name and contact address or telephone number of person before whom the declaration is made, legibly written, typed or stamped / (5)
...... ………...... ………...... …..
...... ……………...... …..
...... ………………...... ….
(Full name and address of witness)
(6) THIS DECLARATION MAY BE MADE BEFORE ANY PERSON WHO HAS ATTAINED THE AGE OF (18) EIGHTEEN YEARS
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NOTE: - A person wilfully making a false statement in a statutory declaration is liable to a penalty of $2000 or imprisonment for 12 months, or both.

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