To a District Court Judge at [specify]
I, [name, occupation, and address of applicant] hereby make application pursuant to section 9 of the Alcoholism and Drug Addiction Act 1966 in respect of [name, occupation, and address of person to whom the application relates], hereinafter in this application referred to as the said person; on the grounds that the said person is an alcoholic *(or drug addict).
I believe that the said person is an alcoholic *(or drug addict) because [set out full reasons for applicant’s belief]:
I am [insert degree of relationship, if any or words “not related”] to the said person.
[To be completed only if the applicant is not a relative† of the said person]: This application is made by me instead of by a relative because [state reason]:
Dated at: [place, date]
Signature of applicant:
Statutory declaration [To be completed unless District Court Judge otherwise permits]
Under section 9(3) of the Alcoholism and Drug Addiction Act 1966 I, [insert name, place of abode, and occupation of applicant or other person making declaration] solemnly and sincerely declare that the statements contained in the foregoing application under section 9 of the Alcoholism and Drug Addiction Act 1966 are true (add “to the best of my knowledge and belief”
if declaration is made by person other than applicant). And I make this solemn declaration conscientiously believing the same to be true and by virtue of the Oaths and Declarations Act 1957.
Declared at: [place, date]
Justice of the Peace, Solicitor, or other person authorised to take a statutory declaration.
*Strike out words which do not apply. |
†Relative, for the purposes of section 9 of the Act, means in relation to a person—
(a)
a person’s spouse, civil union partner, or de facto partner:
(b)
the person’s parent, grandparent, sibling, half-sibling, child, grandchild, or step-child:
(c)
the person’s step-parent; but if the person is under the age of 18 years, only if the step-parent shares responsibility for the day-to-day care of the person with a parent of the person:
Schedule form 3: amended, on 26 April 2005, by section 12 of the Relationships (Statutory References) Act 2005 (2005 No 3).
Schedule form 3: amended, on 1 April 1980, pursuant to section 18(2) of the District Courts Amendment Act 1979 (1979 No 125).