State of Victoria
Affidavit
I, ___________________________________________________________________
of ___________________________________________________________________
make oath and say:-
Sworn at
this
day of
20
,
…………………………………
Signature of deponent making this affidavit
before me:
………………………..
Signature of authorised witness
The authorised witness must print or stamp his or her name, address, and title under section 123c of the Evidence
(Miscellaneous Provisions) Act 1958 (as of 1 January 2010), (previously Evidence Act 1958), (e.g. Justice of the
Peace, Current Legal Practitioner, Registrar of the Magistrates Court, Sergeant of Police, Member of the
Parliament of Victoria)