Statutory Declaration
ABN 42 686 389 537 – PO BOX 151, KYNETON VIC 3444
T 03 5422 0322 – F 03 5422 3623 – mrsc@mrsc.vic.gov.au – www.mrsc.vic.gov.au
Missing Garbage, Recycle or Green Collection Bin
I, Mr / Mrs / Miss / Ms
(Full name)
of
(Residential address)
in the State of Victoria do solemnly and sincerely declare that the:
Garbage 140 litre bin
Recycle 240 litre bin
Green waste 240 litre bin
supplied to:
(insert address from which the bin is missing, if same as residential address
listed above, write ‘as above’)
This bin has been missing since:
(Date on which you last saw the bin)
Additional comments:
I acknowledge that this declaration is true and correct and I make it in belief that a person
making false declaration is liable to the penalties of perjury.
Signature of person making the declaration:
Declared at
in the State of Victoria on the
day of
20
Phone / Mobile:
Before me
Signature:
Print name:
Status:
Justice of the Peace or Bail Justice
Member of the Police Force
Person authorised under Section 107A of the Evidence Act 1958 to witness the Signing of
Statutory Declaration (1).