Document ID: chunk:federal_register_of_legislation:F2024C00687:schedule:1:p3
Version: federal_register_of_legislation:F2024C00687
Segment Type: schedule
Provision Reference: sch 1 (pt 3/9)
Character Range: 157609–160429

the day the donor's sample is taken.

PART 1
Part 1 must be completed if the person swearing or affirming the affidavit is the donor.

   1. I am the person appearing in the photograph attached to this affidavit, being Attachment 'A'.

   2. My racial background is (insert details).

   3. In the last 2 years:
     (a) I *have/*have not suffered from leukaemia;
     (b) I *have/*have not received a bone marrow transplant.

   *4. The particulars of the *leukaemia/*bone marrow transplant are as follows:
    (insert particulars).

   5. I *have/*have not received a transfusion of blood or a blood product within the last 6 months.

   *6. The particulars of the transfusion of blood or blood product are as follows:
    (insert particulars).

   7. I consent to:
     (a) the taking of *a bodily sample/*bodily samples from me on (insert date sample is to be taken) at (insert place sample is to be taken) for the purposes of *a parentage testing procedure/*parentage testing procedures; and
     (b) the carrying out of *that procedure/*those procedures on the *sample/*samples.
PART 2
Part 2 must be completed on behalf of a child or adult who is not capable of swearing or affirming the affidavit. Under subsection 69Z(2) of the Act, a parentage testing procedure must not be carried out in relation to a child without the consent of a parent or guardian of the child or a person who, under a specific issues order, is responsible for the child's long‑term or day‑to‑day care, welfare and development.

   1. I am the (state relationship or other status in relation to the donor) of (insert name of donor) who was born on (insert date of birth of donor).

   2. (insert name of donor) is the person appearing in the photograph attached to this affidavit, being Attachment 'A'.

   3. (insert name of donor) is a person whose racial background is (insert details).

   4. In the last 2 years:
     (a) the donor *has/*has not suffered from leukaemia;
     (b) the donor *has/*has not received a bone marrow transplant.

   *5. The particulars of the *leukaemia/*bone marrow transplant are as follows:
    (insert particulars).

   6. The donor *has/*has not received a transfusion of blood or a blood product within the last 6 months.

   *7. The particulars of the transfusion of blood or blood product are as follows:
    (insert particulars).

   8. I consent to:
     (a) the taking of *a bodily sample/*bodily samples from the donor on (insert date sample is to be taken) at (insert place sample is to be taken) for the purposes of *a parentage testing procedure/*parentage testing procedures; and
     (b) the carrying out of *that procedure/*those procedures on the *sample/*samples.

*SWORN/*AFFIRMED by the
deponent at

on 20

 (Signature of deponent)

BEFORE ME: (insert name of person
before whom