Birth
Registration
Statement for
Same Sex Parents
__________________
Northern Territory of Australia
Births, Deaths and Marriages Registration Act and Regulations 1996
Please submit this ORIGINAL ONLY. Faxed copies or photocopies will NOT be accepted.
This is for registration purposes only; a Birth Certificate is NOT issued automatically
The form can be hand delivered or posted to the addresses below:
Lodge this form at:
Darwin Palmerston Alice Springs
Registrar of Births, Deaths & Marriages Farrar Medical Precinct Deputy Registrar of Births, Deaths & Marriages
Ground Floor Nichols Place Palmerston Community Care Centre Ground Floor Centre Point Building
Cnr Cavenagh & Bennett Streets Cnr Temple Terrace & Roystonea Avenue Cnr Gregory Terrace & Hartley Streets
GPO Box 3021 GPO Box 3021 PO Box 8043
DARWIN NT 0801 DARWIN NT 0801 ALICE SPRINGS NT 0871
Phone: (08) 8999 6119 Phone: (08) 8999 6119 Phone: (08) 8951 5338
Fax: (08) 8999 6324 Fax: (08) 8999 6324 Fax: (08) 8951 5340
Opening Hours: 8am - 4pm Monday to Friday Please call the office for opening hours Opening Hours: 8am - 4pm Monday to Friday
FOR OFFICE USE ONLY
Registered No:
Session No:
Application No:
This registration form is for Northern Territory births only.
You are required by law to register the birth of your child
within 60 days of the birth. Registration is free.
Registration is compulsory for all babies born in the
Northern Territory. If you do not register your child’s birth,
you will not be able to obtain a Birth Certificate for the child.
Penalties such as a fine or imprisonment apply for failing to
register a birth and for giving false or misleading
information.
The child’s name (surname and given names) is a matter
of choice for the parents, except that the Registrar can
refuse to register a name which is obscene or offensive, is
unduly long, or is contrary to the public interest.
The naming of a still-born child is optional.
Please note that a birth certificate is not issued
automatically and must be applied for separately.
a – Child’s Name
Surnames of Child
Given Names of Child
b – Child’s Birth Details
Sex of Child Date of Birth of Child
Male Female / /
D M Y
Unspecified
If Multiple Birth, state order *Birth Weight
(eg 1 of 2 for 1
st
Twin)
*Time of Birth
Was the Child Born Alive?
Yes No
Place of Birth – If Born in Hospital
If Born Elsewhere – Exact Place of Birth
(Full Address)
Suburb/Town/City
*Is the Child of Australian Aboriginal or Torres Strait
Islander origin?
No Yes, Aboriginal origin
Yes, Torres Strait Islander origin
b – Child’s Birth Details Cont.
Doctor(s) Present at Birth
Midwife(s) Present at Birth
Health Worker/Other Person(s) Present at Birth
(e.g. FULL NAME(S) of Family or Friends Present
c – Natural Mother/First Parent Details
Current Surname of Mother
Maiden Surname (Birth Name)
All Given Names of Mother
Date of Birth of Mother
/ /
D M Y
Age of Mother at Birth of Child Years
Mother’s Full Place of Birth
Suburb/Town/City
State/Country
Please Note: All fields marked with an * are for statistical
purposes only. This information will NOT be printed on the Birth
Certificate
of
grams
am/pm
am /
pm
c – Natural Mother/First Parent Details Cont.
*If Born Overseas, how long have you been in Australia?
years/months
Usual Occupation
Full Residential Address (Not PO Box Address)
*Is the Natural Mother/First Parent of Australian Aboriginal
or Torres Strait Islander origin?
No Yes, Aboriginal origin
Yes, Torres Strait Islander origin
d – Other/Second Parent Details
Current Surname of Other/Second Parent
Maiden Surname (Birth Name)
All Given Names of Other/Second Parent
Date of Birth of Other/Second Parent
/ /
D M Y
Age of Other/Second Parent at Birth of Child Years
Full Place of Birth of Other/Second Parent
Suburb/Town/City
State/Country
*If Born Overseas, how long have you been in Australia?
years/months
Usual Occupation
Full Residential Address (Not PO Box Address)
*Is the Other/second Parent of Australian Aboriginal or
Torres Strait Islander origin?
No Yes, Aboriginal origin
Yes, Torres Strait Islander origin
Specification of Parents Title on Birth
Certificate
(Please Note: Each Parent must have a different title)
Preferred Parentage Title of Natural Mother/First
Parent
e.g. Mother/Birth Mother/Parent
(Will default to “Mother” if left blank)
Preferred Parentage Title of Other/Second Parent
e.g. Other or Second Parent/Second Mother/Parent
(Will default to “Parent” if left blank)
e – Marriage Details
Date of Marriage
/ /
D M Y
Full Place of Marriage
City/State/Country
Is this a traditional Aboriginal Marriage? Yes No
Note: details unable to be verified
Following registration, if parents subsequently marry, they may apply to
have their date and place of marriage included at no cost.
f – Previous Children of this Relationship
Please enter details in order of birth
Please include legally adopted children
If deceased please enter “D” in the age column
If not born alive please enter “SB” in age column
If there are no previous children of this relationship,
please write ‘None’ in the first column
Given Names Only
Sex
Date of Birth
Age
g - *Other Children of the Natural Mother but
not of this Relationship (This section is for statistical
purposes only. This information will NOT be printed on the
child’s birth certificate)
Please enter details in order of birth
Please include legally adopted children
If deceased please enter “D” in the age column
If not born alive please enter “SB” in age column
If there are no previous children of this relationship,
please write ‘None’ in the first column
Given Names Only
Sex
Date of Birth
Age
h – Certification by Parents
The PARENTS OF A CHILD are JOINTLY RESPONSIBLE for
having the child’s birth registered and BOTH MUST SIGN the Birth
Registration Statement.
If only one parent has signed, an additional form should be
attached explaining why the other parent was unable to sign.
If the Registrar of Births, Deaths and Marriages wishes to obtain
particulars that have not been included in the Birth Registration
Statement, he or she has powers under the Act to make further
inquiries.
If both parents are unable to sign, this statement may be lodged by
a person who has knowledge of the relevant facts. The person
should state their relationship (if any) to the child.
Certification by Natural Mother/First Parent
Certification by Other/Second Parent
Please ensure that all details provided are correct as any
changes/corrections will incur a fee. This Office is also unable to
give Legal Advice.
Please ensure that all details provided are correct as any
changes/corrections will incur a fee. This Office is also unable to
give Legal Advice.
I (Full Name of Natural Mother/First Parent)
I (Full Name of Other/Second Parent)
Of (Postal Address and Postcode)
Of (Postal Address and Postcode)
postcode
postcode
Telephone No (Business Hours)
Telephone No (Business Hours)
declare that I am the de facto partner of the Other/Second Parent
and have undergone a fertilisation procedure with the consent of
my de facto partner, as a result of which I became pregnant and
this child was born. I hereby certify that the information on this
statement is to the best of my knowledge and belief, correct for
the purposes of including in the Register of Births.
declare that I am the de facto partner of the Natural Mother/First
Parent who underwent a fertilisation procedure with my consent,
as a result of which she became pregnant and this child was
born. I hereby certify that the information on this statement is to
the best of my knowledge and belief, correct for the purposes of
including in the Register of Births.
Signature of Natural Mother/First Parent
Signature of Other/Second Parent
Date / /
D M Y
Date / /
D M Y
Name of Witness
(BLOCK LETTERS – Any Independent person over the age of 18)
Name of Witness
(BLOCK LETTERS – Any Independent person over the age of 18)
Telephone No of Witness (Business Hours)
Telephone No of Witness (Business Hours)
Signature of Witness
Signature of Witness
Date / /
D M Y
Date / /
D M Y
PRIVACY STATEMENT
The Office of Births, Deaths and Marriages is collecting the information on the form so that it can be recorded and preserved in the Register of Births and
in appropriate cases, may be accessed by government agencies, private organisations and members of the public. The collection of the information is
required by the Northern Territory Births, Deaths and Marriages Registration Act 1996.The Office of Births, Deaths and Marriages usually gives some or
all of this information to the Australian Bureau of Statistics and other persons or organisations who have adequate reasons for accessing the information
and who meet the requirements of the Births, Deaths and Marriages Registration Act 1996 or the Access Policy issued under the Act. Copies of the
Access Policy can be obtained from the Office. Failure to provide the information may result in penalties, incomplete registration entries and the non-issue
of certificates. Your personal information provided in this form can be accessed by you on request. If you have any queries please contact the Deputy
Registrar on (08) 8999 6119.
