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Internal Affairs Te Tari Taiwhenua

BDM130

General identity declaration.

Reference number, if known ^

Warnings: 
It is an offence, punishable by imprisonment and/or a fine of up to $10,000, to make a false statement to obtain a certificate, printout or a source document, or to provide any means of identification knowing that it is false or is suspected to be forged or falsified.
It is an offence to make any statement that is false for the purpose of the recording information under the Births, Deaths, Marriages, and Relationships Registration Act 1995.

Instructions:
If you have any questions or you are unsure about how to complete this form please contact us.
Within New Zealand Freephone 0800 22 52 52
Outside New Zealand phone +64 9 339 0852

1. The applicant must fully complete both Parts A and B
2. Part C must be completed by any other person 16 years of age or older

Part A. My Details (as the applicant).
Current name.
Surname  ^
First names ^

Name at birth (if different from above).
Surname at birth (if different from above) ^ 
First names at birth (if different from above) ^

Place and date of birth. 
Place of birth (town or city) including country if not New Zealand ^
Date of birth (DD/MM/YYYY) ^

Your daytime phone number (daytime) ^
Your email address ^

Part B. My declaration (the applicant must complete)
I declare that the information about me that is entered on this form is true and correct.
Signature ^
Date signed (DD/MM/YYYY) ^

If applying on behalf of a company state their name below and include an original signed request on letterhead. ^

Your name, or if applicable, the company name, will be entered in the Access Register. For information about the Access Register visit www.govt.nz/bdm

Part C. Referee’s declaration (any other person 16 years of age or older must complete).

I am 16 years of age or older and have known the applicant for at least 6 months or have seen a government issued photo identification of the applicant and I am satisfied the information about the applicant’s identity stated in this form is true and correct.

Signature of referee ^
Date signed (DD/MM/YYYY) ^

Full name of referee ^
Phone number of referee ^

Contact address of referee ^

Privacy Statement. The information on this form is collected under the Births, Deaths, Marriages, and Relationships Registration Act 2021.
As part of processing your request, your identification details will be checked against other records held by the Department of Internal Affairs or other government agencies, as authorised by law.

Last updated 15 June 2023.