Australia Form 1195 – Fill Out and Use This PDF

Identity declaration

Form

1195

Form 1195 Identity declaration is to be completed and provided to the Department of Immigration and Citizenship (the department):

•for each additional child if you have more children than the space on your citizenship application form allows, or

•if you have applied for citizenship online. A separate form 1195 must be provided for each person included in the online application.

Important – Please read this information carefully before you complete this form. Once you have completed this form we strongly advise that you keep a copy for your records.

Integrity of application

The department is committed to maintaining the integrity of the visa and citizenship programs. If you or a third party acting on your behalf provide, or have provided in a previous application, false or misleading information or documents (either knowingly or otherwise), this application may be refused. In addition, you may be prosecuted under the Migration Act 1958 and/or the Australian Citizenship Act 2007. If information or documents are found to be fraudulent or misleading after you become an Australian citizen, you may be prosecuted and may be subject to revocation of your Australian citizenship.

Identity declaration

Note: Applications for Australian citizenship cannot be approved where a person’s identity is not able to be verified.

The identity declaration must be completed and signed by an Australian citizen who:

•has known you for at least one year and belongs to a profession on the list on pages 1 and 2, and

•is not related to you by birth, marriage or de facto relationship, and

•is easy to contact by telephone during normal working hours.

The person who signs the declaration must also write on the back of your photograph the words: This is a true photograph of (your full name) and sign the back of the photograph using the same signature as on the declaration.

The photograph should be carefully attached to the front of the application form without obscuring the image, or you can place the photograph in a plastic sleeve or envelope and staple it to the form.

The photograph must be:

•no more than 6 months old

•a full-face view of your head and shoulders (untinted prescription glasses can be worn – a photograph that shows facial features only is acceptable if you wear a head covering for religious reasons)

•of good quality, in colour, against a plain, light coloured background (laser copies are not acceptable).

Note: If you are outside Australia when applying you can have the identity declaration completed by a citizen of your country of residence who has known you for at least one year and belongs to a profession on the list on pages 1 and 2.

For children under 6 years of age the photograph may be endorsed and the declaration made by an Australian citizen who has known the applicant for less than 12 months and belongs to one of the professions or occupations listed on pages 1 and 2.

If the child is overseas the photograph may be endorsed by a citizen of the child’s country of residence who belongs to one of the professions or occupations listed on pages 1 and 2.

People from the following list of professions and occupations can complete the identity declaration

1.Australian Consular Officer or Australian Diplomatic Officer (within the meaning of the Consular Fees Act 1955)

2.Bailiff

3.Bank officer with 5 or more years of continuous service

4.Building society officer with 5 or more years of continuous service

5.Chiropractor (licensed or registered)

6.Clerk of court

7.Commissioner for Affidavits

8.Commissioner for Declarations

9.Credit union officer with 5 or more years of continuous service

10.Dentist (licensed or registered)

11.Fellow of the National Tax Accountant’s Association

12.Finance company officer with 5 or more years of continuous service

13.Judge of a court

14.Justice of the peace

15.Legal practitioner (licensed or registered)

16.Magistrate

17.Marriage celebrant licensed or registered under Subdivision C of Division 1 of Part IV of the Marriage Act 1961

18.Master of a court

19.Medical practitioner (licensed or registered)

20.Member of Chartered Secretaries Australia

21.Member of Engineers Australia, other than at the grade of student

22.Member of the Association of Taxation and Management Accountants

23.Member of the Australian Defence Force with 5 or more years of continuous service

24.Member of the Institute of Chartered Accountants in Australia, the Australian Society of Certified Practicing Accountants or the National Institute of Accountants

25.Member of the Parliament of the Commonwealth, a state, a territory Legislature, or a local government authority of a state or territory

26.Minister of religion licensed or registered under Subdivision A of Division 1 of Part IV of the Marriage Act 1961

27.Nurse (licensed or registered)

28.Optometrist (licensed or registered)

29.Permanent employee of Commonwealth, state or local government authority with at least 5 or more years of continuous service

30.Permanent employee of the Australian Postal Corporation with 5 or more years of continuous service

31.Pharmacist (licensed or registered)

32.Physiotherapist (licensed or registered)

33.Police officer

34.Psychologist (licensed or registered)

35.Registrar, or Deputy Registrar, of a court

36.Sheriff

37.Teacher employed on a full-time basis at a school or tertiary education institution

38.Veterinary surgeon (licensed or registered).

About the information you give

The department is authorised to collect personal information and personal identifiers for the purposes of administering the Australian Citizenship Act 2007 (the Act) and the Australian Citizenship Regulations 2007.

Under the Privacy Act 1988 (Cth) (the Privacy Act), the department may disclose your personal information in various circumstances, including where such disclosure is consistent with the department’s disclosure practices of which you are reasonably likely to have been aware.

It is the department’s practice to disclose your personal information other than personal identifiers to other Commonwealth (and in some circumstances, state and territory) Government agencies to confirm your identity and for other purposes connected with the Act, or to verify with the issuing agency, the authenticity of a document you have presented to the department, or in some cases to assist other agencies to administer their legislation.

Agencies to which the department may disclose your personal information other than personal identifiers include but are not restricted to:

•Department of Foreign Affairs and Trade (DFAT) for the purpose of administering the Australian Passport Act 2005. The department discloses information to DFAT concerning your citizenship status

•Centrelink for the purpose of administering the Social Security (Administration) Act 1999 and Family Assistance (Administration) Act 1999

•Medicare and Centrelink for the purpose of administering the citizenship test

•Commonwealth, state and territory police and other agencies to help assess character requirements for citizenship

•Local government councils and other organisations for the purpose of conducting and hosting citizenship ceremonies

•Federal, state and territory Members of Parliament and local government councillors for the purpose of formally welcoming new citizens into the Australian community

•Australian Electoral Commission (AEC) for the purpose of administering the Commonwealth Electoral Act 1918. The AEC is authorised to collect information such as your name, date and place of birth, citizenship status, address and contact details for the purposes of maintaining the electoral roll. This information will be used to ascertain your eligibility for enrolment as an elector in elections in Australia. The AEC may contact you about proposed action they may take to appropriately update the electoral roll. For further information call 132 326 or visit www.aec.gov.au

Personal identifiers collected under the Act are photographs and signatures. The department and DFAT have signed

an arrangement in accordance with the Act that permits disclosure of your personal identifiers for the purposes of administering the Australian Passport Act 2005. If your application for Australian citizenship is approved, your photograph, client number, name, date of birth and gender will be provided to DFAT.

The Act permits disclosure of your personal identifiers in the following circumstances:

•for the purposes of the Act or its regulations, or of the

Migration Act 1958 or the Migration Regulations 1994, or

•for the purpose of administering or managing the storage of identifying information, or

•for the purpose of making the identifying information in question available to you, or

•to an agency of the Commonwealth, a state or a territory in order to verify that you are an Australian citizen, or

•under an arrangement entered into with an agency of the

Commonwealth, or with a state or territory or an agency of a state or territory, for the exchange of identifying information, or

•when reasonably necessary for the enforcement of the criminal law of the Commonwealth, a state or a territory, or

•when required by an Australian law, or

•for the purpose of a proceeding before a court or tribunal relating to you, or

•for the purpose of an investigation by the Privacy

Commissioner or the Ombudsman relating to action taken by the department, or

•if the disclosure takes place with your written consent.

Your personal identifiers can also be disclosed if a person believes on reasonable grounds, that the disclosure is necessary to prevent or lessen a serious and imminent threat to the life or health of you or of any other person.

Citizenship testing in regional Australia by the Department of Human Services

Under the Australian Citizenship Act 2007, the department has authorised selected officers of the Department of Human Services to be citizenship test administrators and conduct citizenship appointments on behalf of the department in selected regional centres.

Test administrators are authorised to collect and access your identifying information such as your photograph and signature, and use it along with personal and identifying information provided to the Department of Human Services by the department to verify your identity and confirm that you are eligible to sit the citizenship test. Personal and identifying information includes your name, date of birth, address, photograph, signature and copies of identity documents.

At the conclusion of your test appointment, the test administrator will electronically transmit the documents and photograph that were used to verify your identity, to the department for storage in the department’s records management system. The test administrator will then securely destroy the personal and identifying information, including electronic records, except for a record of your name, date of birth and the date of your appointment.

Identity declaration

Form

1195

Please use a pen, and write neatly in English using BLOCK LETTERS. Corrections made with liquid paper are not acceptable.

Applicant details

1Family name Given names

DAY MONTH YEAR

Date of birth

Current residential address

Note: You must tell the department if your address changes after you lodge this form.

POSTCODE

Current postal address

(If the same as your residential address, write ‘AS ABOVE’)

PHOTOGRAPH

You must attach the endorsed photograph of the applicant to this page.

The photograph must be attached without obscuring the image, or can be placed in a plastic sleeve and stapled to this page.

The photograph IS NOT TO BE SIGNED BY THE APPLICANT

The person who has completed the Identity declaration should also endorse the photograph.

Example of photograph requirements

Note: You must tell the department if your address changes after you lodge this form.

POSTCODE

Telephone numbers

Work	(AREA CODE	)
Home
	(AREA CODE	)

PHOTOGRAPH FRONT

Min 32mm	Max 36mm
	SIZE

PHOTOGRAPH BACK

“This is a true photograph of”

JOHN CITIZEN

(full name of applicant)

PSmith

(signature)

Mobile/cell

Transaction Reference Number (the number that you were given when you lodged your online application)

Details of the person who is making the identity declaration

Identity declaration

2I declare that I have known (full name of the applicant) Family name

Given names

for		year(s) and vouch for his/her identity.
I have endorsed the back of his/her photograph.
Signature
of person
making this		-
declaration
		DAY	MONTH	YEAR

3Family name Given names

Address (home or business)

				POSTCODE
Telephone numbers
Work	(AREA CODE	)
Home	(AREA CODE	)
Mobile/cell
Are you an Australian citizen?
		Yes		No

Date

Profession or occupation group number from pages 1 or 2

Signature of responsible parent

-

Work

Home Mobile/cell

COUNTRY CODE		AREA CODE	NUMBER
(	)	(	)
(	)	(	)