*** Transcriber's Note: Please set your voice synthesiser to read most punctuation. When you encounter the caret sign at the end of a line, please enter the applicable information, if necessary. *** Internal Affairs Te Tari Taiwhenua BDM36 Request for Name Change within 2 Years of Birth. He tono ki te r?hita i t?tahi Panoni Ingoa i roto i te 2 Tau o te Wh?nautanga. If the child's birth is registered outside New Zealand use the Application to register a Name Change for person aged under 18 who has not been married, in a civil union or de facto relationship (BDM122) at www.govt.nz/bdm Guidelines about the new name. What must the name consist of? The new name must consist of one surname, and one or more other names, unless your religious or philosophical beliefs, or cultural traditions require the person to bear only one name - in which case attach a letter of explanation. What is not acceptable? The new name (or combination of names) may not be accepted for registration if: • it might cause offence to a reasonable person; or • it is unreasonably long (that is, it should be less than 100 characters long, including spaces); or • without adequate justification, it is, includes, or resembles, an official title or rank (in which case attach a letter of explanation); or • it is not a name (for example, it must not include numbers or symbols). If this is the second name change. If the child’s name has been changed previously then you must give special reasons as to why it is appropriate to change their name again. If this is the case explain the special reasons in a separate letter. Certificate showing the new name. Birth registered in New Zealand. Any new Birth Certificate that is issued will show the new name as well as all previous names. A new birth certificate can be made available after registration, on payment of an additional fee. How long will it take? Applications will be processed within 15 working days, from receiving a correct and complete application (plus postage time). If you have requested a certificate showing your new name, it will be issued as soon as the name change has been processed. You must make true statements. You must make true statements when completing this application. If you make, or cause to be made, any false statement you will be liable on conviction to a fine or up to 5 years imprisonment, or both. Post the form and appropriate fee(s) to either of: New Zealand. Name Change Team Births, Deaths, and Marriages Department of Internal Affairs PO Box 10-526 Wellington 6143 New Zealand Sydney. Births, Deaths and Marriages Department of Internal Affairs GPO Box 365 Sydney New South Wales 2001 Australia London. Births, Deaths and Marriages Department of Internal Affairs New Zealand House 80 Haymarket London SW1Y 4TQ United Kingdom All the child’s legal guardians must sign this request. The guardians of the child whose name is to be changed should give all the information requested on this form about themselves and about that child. The child’s father and mother are usually joint guardians. The father and the mother of a child are guardians jointly of the child unless the child’s mother is the sole guardian of the child. If the child is legally adopted by opposite-sex or same-sex parents, those parents are guardians of the child through the adoption. Father as guardian. The mother and father are both guardians if they jointly registered the birth of the child on or after 1 July 2005 by completing and signing the Notification of Birth for Registration form (BDM27). The mother is the sole guardian. If a child is conceived on or after 1 July 2005, the child’s mother is the sole guardian of the child if the mother was not: Married to, nor in a civil union with, the father of the child at any time during the period beginning with the conception of the child and ending with the birth of the child; and not Living with the father of the child as a de facto partner at any time during that period. If the child is born as a result of an assisted reproduction procedure (such as donor insemination) to a mother acting alone, and the donor is not the mother’s partner (i.e. not in a marriage, civil union or de facto relationship), and the donor does not become the mother’s partner between conception and notification of the birth for registration, then the mother is the sole guardian. Appointment of 1 or more additional guardians. A testamentary guardian of the child appointed by the deceased parent under section 26(2) of the Care of Children Act 2004 or section 7(2) of the Guardianship Act 1968. All Court appointed/approved guardians. A certified copy of the Court appointment as a guardian should be attached to this declaration. A guardian may act alone. In some circumstances a guardian may act alone if the other guardian(s) is/are dead, unknown, missing, of unsound mind or unable to act because of a medical condition; or If Family Court approval is obtained. Appropriate evidence must be attached to this declaration. Other parent. If the child was born as a result of an assisted human reproduction procedure (such as artificial insemination), and the mother was living in a marriage, civil union or de facto relationship with a man or a woman who had consented to her undergoing the procedure, and the man’s or woman’s name is recorded on the child’s birth registration, then that man or woman must also sign this declaration. Contact Details. Births, Deaths, Marriages and Citizenship: Website www.govt.nz/bdm Freephone (within New Zealand) 0800 22 52 52. If overseas phone + 64 4 463 9362 Email bdm.nz@dia.govt.nz Privacy Statement. The information provided on this form is collected under the Births, Deaths, Marriages, and Relationships Registration Act 1995 (the “BDMRR Act). A person who makes, or causes to be made, a false statement on this form will be liable on conviction to a fine or term of imprisonment, or both. The information will be held on a public register, and may generally be accessed by any person on application (e.g. as a certificate or printout). Births, Deaths, Marriages and Citizenship may also release it to certain government agencies and foreign registration authorities, as authorised by law. The BDMRR Act governs access to registered information. Information about your rights to access and, where appropriate, correct the information is available on our website www.govt.nz/bdm or Freephone 0800 22 52 52. The information on this form is collected under the Births, Deaths, Marriages, and Relationships Registration Act 1995. As part of processing your request, your identification details will be checked against other records held by Births, Deaths, Marriages and Citizenship or other government agencies, as authorised by law. BDM36 Internal Affairs Te Tari Taiwhenua. Request for name change within 2 years of birth. He tono ki te r?hita i t?tahi Panoni Ingoa i roto i te 2 Tau o te Wh?nautanga. If this is for a second name change you must explain the special reasons why it is necessary. If there are more than two guardians continue on separate form. Provide certified true copies or originals of any documents you include with this application. 1. Old name. Name at birth is (if legally adopted then enter the names given after the adoption) All first and middle names ^ Surname ^ If the guardians have previously registered a name change for the child in New Zealand or overseas. The name below is the name changing from, if it is different from the name at birth. All first and middle names of most recently registered name change ^ Surname of most recently registered name change ^ 2. Date of birth. Date of birth (DD/MM/YYY) ^ 3. Place of birth. Town or City. ^ Country of birth (if not New Zealand). ^ 4. New name (the new name must comply with the “Guidelines about the new name” in the notes pages at the start of this application) All first names of the new name ^ Surname of the new name ^ We are acting together to complete this declaration. Yes or No. ^ If yes, go to question 6. 5. If acting alone as a guardian. I, as the child’s mother, am the sole guardian because I was not married to, nor in a civil union with, the father of the child at any time during the period beginning with the conception of the child and ending with the birth of the child; and I was not living with the father of the child as a de facto partner at any time during that period, and none of the exceptions (below) apply. Yes or No ^ Exceptions. a. The mother and father jointly registered the birth by completing and signing the Notification of Birth for Registration form (BDM27). b. A testamentary guardian of the child has been appointed by the deceased parent under section 26(2) of the Care of Children Act 2004 or section 7(2) of the Guardianship Act 1968. c. The Court has appointed any other person(s) a guardian. The guardian(s) is/are missing. Yes or No ^ State the actions that you have actually taken to contact the other guardian(s). This may include searching the electoral roles, the Internet, asking family and friends or former employers. I, as the child’s mother, am the sole guardian because the child was born as a result of an assisted reproduction procedure (such as donor insemination) to me acting alone, and the donor is not my partner (i.e. not in a marriage, civil union or de facto relationship), and the donor did not become my partner between conception and notification of the birth for registration. Yes or No ^ The guardian(s) is/are dead. Yes or No ^ If died in New Zealand, print the deceased’s name, date of death and place of death. If died overseas, include a certified true copy (or original) of the deceased’s death certificate. The Family Court has given consent for me to act alone. Yes or No ^ Attach a copy of the Family Court order. The guardian is unable to act because of a medical condition. Yes or No ^ Provide evidence from a Registered Medical Doctor. The other guardian is unable to act as they are of unsound mind. Yes or No ^ Provide evidence from a Registered Medical Doctor. Describe. ^ Instructions 1. The guardian(s) must fully complete both Parts A and B. 2. If ordering a birth certificate, Part C must be completed by any other person 16 years of age or older. 6. Your full name, occupation and residential address (If there are more than two guardians continue on separate form) Guardian 1. Guardian 1's First names. ^ Guardian 1's Surname. ^ Guardian 1's daytime landline or mobile phone number. ^ Guardian 1's email address. ^ Relationship to child (e.g. mother/father). ^ Residential address - this is not a PO Box. Flat no. ^ Street no. ^ Street. ^ Suburb or rural locality. ^ City, town or district. ^ Postcode. ^ Country (if not New Zealand). ^ Guardian 2. Guardian 2's First names. ^ Guardian 2's Surname. ^ Guardian 2's daytime landline or mobile phone number. ^ Guardian 2's email address. ^ Relationship to child (e.g. mother/father). ^ Residential address - this is not a PO Box. Flat no. ^ Street no. ^ Street. ^ Suburb or rural locality. ^ City, town or district. ^ Postcode. ^ Country (if not New Zealand). ^ 7. If this is the second name change explain why you are applying again. ^ I authorise any necessary additional enquiries including the disclosure of personal information about myself and the person whose name is being changed for the purpose of determining eligibility for this name change application. My authorisation includes any information held by the Department of Internal Affairs or another NZ government agency. If I submit an application for New Zealand citizenship or a New Zealand passport at the same time as this application is submitted, I authorise any necessary additional enquiries including the disclosure of personal information about myself and the person whose name is being changed so both applications can be processed. I/We solemnly and sincerely declare that the information in this name change request is true, accurate and complete. 8. Signatures (If there are more than two guardians continue on separate form). Guardian 1 Signature. ^ Date signed. (DD/MM/YYYY) ^ Guardian 2 Signature. ^ Date signed. (DD/MM/YYYY) ^ 9. Fees and payment details. DO NOT POST CASH. Application fee to register a name change. $55.00 If you require evidence of the new name order a certificate: A certificate is an official document containing registered information. Standard certificates have a plain white background and no additional images. There are two types of decorative certificates available. The forest decorative certificate shows a stream surrounded by native bush, including koru, fern and k?whai. The beach decorative certificate shows a woman sitting with a baby on a beach. The women looks out towards the sea as her family waves back at her. Please indicate the number you need for each certificate design. Standard and Forest. Two certificate package $55.00 Enter quantity below. ^ Standard and Beach. Two certificate package $55.00 Enter quantity below. ^ Forest. $35.00 each. Enter quantity below. ^ Beach. $35.00 each. Enter quantity below. ^ Standard. $33.00 each. Enter quantity below. ^ For a limited time only: All Blacks theme NZ Birth Certificate Standard and All Blacks. Two certificate package $55.00 Enter quantity below. ^ All Blacks. $35.00 each. Enter quantity below. ^ Certificate fee (optional). Enter total amount for the certificate(s). $ ^ Courier fee (optional) To a New Zealand address add $5.00 Yes or No ^ To an overseas address (contact us for details) Yes or No ^ Total amount to pay $ ^ If paying in person at an Identity Services Office we also accept EFTPOS and cash payments. I chose the following method to pay. I have enclosed a New Zealand cheque or International bank draft in NZ dollars made out to the Department of Internal Affairs. Note: Australian money orders can only be receipted at the Sydney office. Yes or No ^ Or Charge my credit/debit card. Yes or No ^ VISA. Yes or No ^ Mastercard. Yes or No ^ Amex. Yes or No ^ Prezzy Card. Yes or No ^ Card number. ^ Expiry date. ^ Cardholder’s name. ^ Cardholder’s signature. ^ Delivery Address, if ordering a certificate. Delivery Name. ^ Flat number (if applicable). ^ Street number. ^ Street. ^ Suburb or rural locality. ^ City, town or district. ^ Postcode. ^ Country (if not New Zealand). ^ HART Register (optional) Only complete and return this page if it is applicable. Human Assisted Reproductive Technology (HART) Register. This section only applies if the person whose name is being changed was born as a result of an assisted reproductive technology procedure using donated sperm, eggs or embryos through a fertility clinic. If information has been provided to Births, Deaths and Marriages for inclusion on the HART Register, it will be updated to include the person’s new name. This means that up-to-date information will be provided to persons who are authorised to access your information under the Human Assisted Reproductive Technology Act 2004. Are you a donor or person born as a result of a HART procedure? Yes, the person whose name is being changed was born as a result of a HART procedure whose details are recorded on the HART Register. ^ If the birth occurred as a result of a donation made after 21 August 2005, information will also be held by the fertility clinic. We can send information about the name change to the fertility clinic, so that the clinic’s records can be updated. Consent for new name to be sent to clinic. I consent to the new name being sent to the fertility clinic named below that holds the information. Yes. ^ Fertility clinic name. ^ Last updated 10 October 2018.