BRS

Form 201

ACT GOVERNMENT

BIRTH REGISTRATION STATEMENT

PRIVACY COLLECTION STATEMENT (PRIVACY ACT 1988 (CWLTH))
PRIVACY NOTES The Births, Deaths and Marriages Registration Act 1997 authorises the Registrar-General to collect the information required by this form for the establishment and maintenance of registers and in processing your application. The Registrar-General prevents any unreasonable intrusion into a persons privacy in accordance with the Privacy Act 1988 (Cwlth). However, the Registrar-General provides identifiable information to law enforcement organisations and authorised organisations that have legal authority to request information under prescribed circumstances. WHY REGISTRATION IS IMPORTANT You are required by law to register the birth of a child within 60 days of the date of the birth. If you fail to lodge a birth registration statement, the Registrar-General may register the birth with incomplete information. The Registrar-General may assign a name to a child if the name stated is a prohibited name or the parents are unable to agree on a name. It is in the best interests of both the parents and the child that the birth is correctly and completely registered. If you do not register your childs birth, you will not be able to obtain a birth certificate for your child. A standard birth certificate provides legal evidence of age, place of birth and particulars of the parent(s), and may be required for school enrolment, drivers licence, employment and government benefits. Commemorative certificates are not generally accepted as a legal document. It is compulsory to register all live births, and in the case of stillbirths where the child is 400 grams or more or of at least 20 weeks gestation. WHO IS RESPONSIBLE FOR REGISTRATION The parent(s) of a child are responsible for having the childs birth registered, and must sign this form, whether or not they are married. The Registrar-General will refrain from entering details of a parent who has not signed this form. In the case of stillbirths the parent(s) may permit hospital staff to complete this form on their behalf, however the parent(s) must still sign the form. You should complete the attached form and deliver or post it to the address below within 60 days of the childs date of birth. The hospital or medical attendant should complete the birth details section of this form. Please print clearly and carefully check that all details provided are correct. Inaccurate information may delay registration of the birth or cause problems in the future. GENERAL INFORMATION Traditional cultural naming practices are acceptable, however legislation prevents non-English symbols from being entered into the register. A parent of a child means the childs mother, father or someone else who is presumed under the Parentage Act 2004 to be a parent of the child. The statistical information relating to Aboriginal or Torres Strait Islander origin are collected for the Australian Bureau of Statistics for health and welfare purposes only. Each parent must initial any alterations made on this form. FEES CURRENT TO 30 JUNE 2009 There is no fee to lodge a birth registration statement, however a fee is applicable if you require a birth certificate. If you wish to apply for a birth certificate you may complete the attached application form, and lodge your application with the birth registration statement. CONTACT DETAILS The Registrar-Generals Office is located at 255 Canberra Avenue, Fyshwick ACT 2609. Our postal address is GPO Box 158, Canberra City ACT 2601. Our office hours are 9:00am to 4:30pm Monday to Friday. You may also download forms and information from our website at www.ors.act.gov.au or contact this office on (02) 6207 0460. Telephone Interpreter Services If English is not your first language, and you need help with this form, please telephone 131 450 for assistance 24 hours a day.

Births, Deaths and Marriages Registration Act 1997 Registrar-Generals Office

Approved form AF 2008 54 approved by Brett Phillips, Registrar-General on 18 June 2008 under section 69 of the Births, Deaths and Marriages Registration Act 1997 (approved forms) and revokes form AF 2007 123.
Authorised by the ACT Parliamentary Counselalso accessible at www.legislation.act.gov.au

BIRTH CERTIFICATE ORDER FORM

It is not compulsory to order a birth certificate at the time a childs birth is registered. If you order a commemorative package you will also receive a standard birth certificate. For security purposes the example commemorative certificates below have been altered. Full examples may be viewed in our office. Please select the type of certificate you wish to order.

Application No

Standard Birth Certificate

Type of Commemorative Certificate: Canberra Capital Bluebell

Commemorative Package
Year 2000 Clowns

Commemorative Certificate Only

Blue Bunny Pink Bunny Teddy Bears Duck

Certificate Type Standard Certificate only Canberra Capital Bluebell Year 2000 Clowns Blue Bunny Pink Bunny Teddy Bears Duck Registered Post TOTAL

Childs Full Name

Date of Birth

Quantity

Price $36.00 $51.00 $51.00 $51.00 $51.00 $51.00 $51.00 $51.00 $51.00 $51.00 $5.00 $ $ $ $ $ $ $ $ $ $ $ $

Amount

All certificates sent by mail attract a $5.00 registered person to person postage fee. Please ensure you add this fee to your payment.

DETAILS OF APPLICANT
Surname Current residential address Given names Postal address if different from residential

Postcode

Postcode

Daytime contact telephone number Relationship to child named on certificate

E-mail address Signature

Reason certificate is required

PAYMENT DETAILS
If you are applying by mail and payment is by credit card please complete the details below. Payment may be made by cash, credit card, EFTPOS, money order or cheque, all cheques and money orders should be made payable to the Registrar-General. Applications paid by personal cheque will be held for 7-10 working days for the cheque to clear. Mastercard Card Number Name of Cardholder Signature of Cardholder Visa Card Amount $ Expiry Date __ __ / __ __

Authorised by the ACT Parliamentary Counselalso accessible at www.legislation.act.gov.au

BRS
Form 201

Registration No

Certificate Applied For (Office use Only) Y

/N

ACT GOVERNMENT

BIRTH REGISTRATION STATEMENT DETAILS OF CHILD TO BE COMPLETED BY PARENT(S)

Surname Given names

Births, Deaths and Marriages Registration Act 1997 Registrar-Generals Office

DETAILS OF CHILD TO BE COMPLETED BY HOSPITAL OR MEDICAL ATTENDANT

Date of birth / / Was child born alive? Time of birth am/pm Gestation if not alive weeks Other witnesses present at the birth Sex If multiple birth (ie 1 of 2) Weight grams of Place of birth (name of hospital or address if other place)

Yes No Medical practitioner, registered nurse or midwife Dr/Rn/Rm

DETAILS OF MOTHER AT TIME OF CHILDS BIRTH

Surname Given names in full Place of birth Suburb/Town State/Country Aboriginal or Torres Strait Islander origin (for Australian Bureau of Statistics purposes only) None Yes, Aboriginal origin Day time contact telephone number Yes, Torres Strait Islander origin Yes, both Aboriginal and Torres Strait Islander origin Signature Maiden name/former surname if any Date of birth Occupation

/ / Residential address at time of the birth of the child

DETAILS OF FATHER
Surname Given names in full Place of birth

PARENT

AT TIME OF CHILDS BIRTH

Former surname if any Date of birth Occupation

/ / Residential address at time of birth of the child Suburb/Town

State/Country Aboriginal or Torres Strait Islander origin (for Australian Bureau of Statistics purposes only) None Yes, Aboriginal origin Day time contact telephone number Yes, Torres Strait Islander origin Yes, both Aboriginal and Torres Strait Islander origin Signature

Authorised by the ACT Parliamentary Counselalso accessible at www.legislation.act.gov.au

DETAILS OF MARRIAGE OR DOMESTIC PARTNERSHIP IF APPLICABLE

Are the parents in a domestic partnership? Yes No Date of marriage Place of marriage / / Suburb/Town State/Country

DETAILS OF OTHER CHILDREN OF THIS RELATIONSHIP

Please enter in order of birth including stillborn and adopted children, if deceased enter d next to the date of birth Given names in full Date of birth / / / / / / / / / / / / / / / / Male / Female

DETAILS OF CHILDREN OF MOTHER NOT OF THIS RELATIONSHIP

Please enter in order of birth, if deceased enter d next to the date of birth no I would like this information to appear on birth certificates yes Given names in full Date of birth / / / / / / Male / Female

DETAILS OF CHILDREN OF FATHER/PARENT NOT OF THIS RELATIONSHIP

Please enter in order of birth, if deceased enter d next to the date of birth no I would like this information to appear on birth certificates yes Given names in full Date of birth / / / / / / Male / Female

DETAILS OF INFORMANT/PARENT COMPLETING THIS FORM

I certify that I have read this form thoroughly and that the information provided, is to the best of my knowledge and belief, true and correct for registration purposes. I understand that it is an offence to make a false or misleading statement in any application or document under the Births, Deaths and Marriages Registration Act 1997. Surname Given names in full Occupation Current residential address Suburb/Town State/Country Relationship to child Signature Day time contact telephone number

Authorised by the ACT Parliamentary Counselalso accessible at www.legislation.act.gov.au