Statutory Declaration - Retirement

1 Statutory Declaration - Retirement I, Surname Given name(s) Address do solemnly and sincerely declare: 1. THAT I AM OVER THE AGE OF 55; 2. THAT I HAVE PERMANENTLY RETIRED FROM THE WORKFORCE; 3. THAT IT IS NOT MY INTENTION TO SEEK EMPLOYMENT IN THE FUTURE; 4. FOR DECLARATIONS MADE IN THE STATE OF QUEENSLAND: (To be signed before a Justice of the Peace, Barrister, solicitor or conveyancer qualified under the law of the Commonwealth or another state, Notary Public, or Commissioner for declarations.) And I make this solemn Declaration conscientiously believing the same to be true and by virtue of the provisions of the Oaths Act 1867 - 1981 FOR DECLARATIONS MADE IN THE STATE OF NEW SOUTH WALES: (To be signed before a Justice of the Peace, solicitor holding a current practising certificate, or Notary Public.)

2 And I make this solemn Declaration conscientiously believing the same to be true and by virtue of the provisions of the Oaths Act 1900. And I make this solemn Declaration as to the matter aforesaid, according to the law in this behalf made and subject to the punishment by law provided for any wilfully false statement in any such Declaration . FOR DECLARATIONS MADE IN THE STATE OF VICTORIA: (To be signed before a Justice of the Peace, or other person able to take Statutory declarations.) And I make this solemn Declaration conscientiously believing the same to be true and by virtue of an Act of the Parliament of Victoria rendering persons making a false Declaration punishable for wilful and corrupt perjury. I acknowledge that this Declaration is true and correct and I make it in the true belief that a person making a false Declaration is liable to the penalties of perjury Place Declared at Date On By Signed (member) Witnessed Signed (witness) Title/Office