To: [Insert name of Commonwealth's Representative]

[Insert Name/description of Contract] ("Contract")

STATUTORY DECLARATION IN RELATION TO PAYMENT OF WORKERS AND SUBCONSULTANTS

Clause 9.12

I, [name of person making the declaration], of [address of person making the declaration], [occupation of person making the declaration], make the following declaration under the Statutory Declarations Act 1959:

1.In this statutory declaration:

"Commonwealth" means Commonwealth of Australia.

"Consultant" means [details of Consultant as appropriate];

"Services" has the meaning given to it in the Contract.

2.I hold the position of [managing director or other title] of the Consultant and am duly authorised by the Consultant to make this declaration on its behalf.

3.I make this declaration on behalf of the Consultant and on behalf of myself.

4.There are no moneys due and payable to any workers at any time employed by the Consultant in respect of any work which the Consultant has carried out for the Commonwealth in relation to the Services or any subconsultants as at [insert date of payment claim to which the declaration is attached], being the date of payment by the Commonwealth for that work.

I understand that a person who makes a false statement in a statutory declaration is guilty of an offence and I make this solemn declaration by virtue of the Statutory Declarations Act 1959, and subject to the penalties under section 11 of the Statutory Declarations Act 1959, and I believe that the statements contained in this declaration to be true in every particular.

______

Signature of declarant

Declaredat on the day of 20 .

Before me: ______

______

Full name of witness

______

Address of witness

______

Qualification of witness

Note 1 A person who intentionally makes a false statement in a statutory declaration is guilty of an offence, the punishment forwhich is imprisonment for a term of 4 years — see section 11 of the Statutory Declarations Act 1959.

Note 2 Chapter 2 of the Criminal Code applies to all offences against the Statutory Declarations Act 1959 — see section 5A ofthe Statutory Declarations Act 1959.

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