New South Wales Consolidated Regulations New South Wales Consolidated Regulations(Clauses 7, 11, 14 and 15)
( Status of Children Act 1996 )
(Clause 7 (1) (a))
Name of child whose parentage is in issue:
Name of donor:
Date of birth of donor:
*Relationship/*Putative relationship of donor to child whose parentage is in issue (if donor is not the child whose parentage is in issue, insert relationship of donor to child):
Date of taking sample from donor:
I, (name), of (address), (occupation) *make oath and say/*affirm:
(Either Part 1 or Part 2 of this form must be completed and duly sworn or affirmed by the person completing it, and the signature witnessed, on 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 (give 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: (give 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: (give 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 section 28 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.
1 I am the (state relationship or other status in relation to the donor) of (name of donor) who was born on (date of birth of donor).
2 (Name of donor) is the person appearing in the photograph attached to this affidavit, being Attachment ‘A’.
3 (Name of donor) is a person whose racial background is (give 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: (give 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: (give 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
on20.
(Signature of deponent)
Before me:
(Signature of person before whom the affidavit is sworn or affirmed)
Attach a recent photograph of the donor named in the affidavit, measuring approximately 45 millimetres by 35 millimetres, that shows a full face view of the donor’s head and the donor’s shoulders against a plain background. The photograph must be marked ‘A’, and must bear a statement, signed by both the person before whom the affidavit is sworn or affirmed and the deponent, identifying it as the photograph mentioned in the affidavit.
*Delete if not applicable.
( Status of Children Act 1996 )
(Clause 11)
Name of child whose parentage is in issue:
1 I, (name of sampler), of (professional address), (occupation), took the bodily *sample/*samples specified below at (time) *am/*pm on (date) at (place of collection) from the following *person/*persons:(a) (name of person and type of bodily sample stated and person’s photograph affixed),*(b) (name of person and type of bodily sample stated and person’s photograph affixed),*(c) (name of person and type of bodily sample stated and person’s photograph affixed),*(d) (name of person and type of bodily sample stated and person’s photograph affixed).
2 When I took the bodily *sample/*samples specified above, I strictly observed the procedures provided under the Status of Children Regulation 2008 .
3 I placed *the bodily sample/*each of the bodily samples specified above in a container that was immediately sealed and then labelled in accordance with clause 10 of the Status of Children Regulation 2008 .
Dated20.
(Signature of sampler)
*Delete if not applicable.
( Status of Children Act 1996 )
(Clause 14)
Name of child whose parentage is in issue:
Part 1
1 I, (name of nominated reporter), of (address), am a person nominated by the laboratory specified below to prepare a report in accordance with clause 14 of the Status of Children Regulation 2008 .
2 I report that a parentage testing *procedure/*procedures, being:*(a) red cell antigen blood grouping,*(b) red cell enzyme blood grouping,*(c) testing for serum markers,*(d) HLA tissue typing,*(e) DNA typing,*has/*have been carried out on the bodily *sample/*samples contained in the sealed *container/*containers bearing the *name/names of the following *donor/*donors:(a) (donor’s name, date of birth and relationship to the child whose parentage is in issue),*(b) (donor’s name, date of birth and relationship to the child whose parentage is in issue),*(c) (donor’s name, date of birth and relationship to the child whose parentage is in issue),*(d) (donor’s name, date of birth and relationship to the child whose parentage is in issue).
3 Each bodily sample referred to in item 2 is the same bodily sample as the bodily sample specified in the statement completed on (date) by (name of sampler) in accordance with clause 11 of the Status of Children Regulation 2008 .
4 The parentage testing *procedure was/*procedures were carried out at (name of laboratory or laboratories).
5 The results of the parentage testing *procedure/*procedures are set out in Part 2 of this report.
*6 I report that the results of the parentage testing *procedure/*procedures carried out on the bodily *sample/*samples of the donors specified above show that (name of putative parent) is not excluded from identification as the *father/*mother of (name of child whose parentage is in issue).
[OR]
*6 I report that the results of the parentage testing *procedure/*procedures carried out on the bodily *sample/*samples of the donors specified above show that (name of putative parent) is excluded from identification as the *father/*mother of (name of child whose parentage is in issue).
*7 I further report that the probability that (name of putative parent) is the genetic *father/*mother of (name of child whose parentage is in issue) has been calculated as follows:[OR]
*Paternity/*Maternity Index (figure) to 1 Relative chance of *Paternity/*Maternity (percentage)%
*7 I further report that the exclusion is based on contradictions to the laws of genetic inheritance in (amount) of the (amount) genetic markers tested. The contradictions occurred in the following genetic markers: (names of genetic markers and whether the contradictions were of the first or second order).
*8 I further report (if necessary, provide further explanation of results detailed in items 6 and 7).
Dated20.
(Signature of nominated reporter)
Part 2
1 The bodily *sample/*samples referred to in Part 1 *was/*were received at (name of laboratory at which the parentage testing *procedure was/*procedures were carried out) on20.
2 The following identification numbers were allocated respectively to the bodily *sample/*samples in the *container/*containers in which the *procedure was/*procedures were carried out:(a) (name of person and identification number),*(b) (name of person and identification number),*(c) (name of person and identification number),*(d) (name of person and identification number).
3 The results obtained from the parentage testing *procedure/*procedures are as follows: (set out the results)
*4 The results set out in item 3 refer to the parentage testing *procedure/*procedures carried out *by me/*under my supervision on (date). The bodily *sample was/*samples were tested against the same reagents and in parallel with appropriate known controls. Results from controls show that all reagents were of correct specificity and normal potency. I am satisfied that the results obtained are true and that they have been correctly transcribed from the laboratory records.
[OR]
*4 The results set out in item 3 refer to the parentage testing *procedure/*procedures carried out *by me/*under my supervision on (date). The bodily *sample was/*samples were tested with the same probes/primers and in parallel with appropriate known controls. Fragment length and/or hybridisation patterns were in accordance with scientifically accepted standards. I am satisfied that the results obtained have been correctly coded from the fragment and/or hybridisation pattern and that they have been correctly transcribed from the laboratory records.
Dated20.
(Signature of person who carried out parentage testing procedure or person under whose supervision procedure was carried out)
*Delete if not applicable.
( Status of Children Act 1996 , section 19)
(Clause 15 (1))
Note:
SIGNATURES MUST BE WITNESSED BY AN AUSTRALIAN LEGAL PRACTITIONER OR BY AN OFFICER OF THE REGISTRY OF BIRTHS, DEATHS AND MARRIAGES NOMINATED BY THE REGISTRAR.
IF A PARTY IS UNAVAILABLE TO SIGN THIS FORM, THE LAST KNOWN ADDRESS OF THE PERSON SHOULD BE PROVIDED IN THE APPROPRIATE SECTION IMMEDIATELY BELOW.
| I (full name of mother) | I (full name of father) |
| of | of |
| Postcode:Ph: | Postcode:Ph: |
CHILD’S PARTICULARS
| Sex: | ||
| (given names) | (family name) | |
| born on// | at, New South Wales. |
FATHER’S PARTICULARS (at time of child’s birth)
| Occupation: | ||
| (given names) | (family name) | |
| born on// | at |
This acknowledgment is made believing that the information provided is true to the best of our knowledge and belief.
(mother’s signature) | (father’s signature) |
| Signed at | Signed at |
| on | on |
| Witnessed by | Witnessed by |
| Qualification | Qualification |
| (Legal practitioner/Registry officer) | (Legal practitioner/Registry officer) |
(name, address and telephone no. of witness) | (name, address and telephone no. of witness) |