Affidavit of [name] [date]

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Form 40 (version 3)
UCPR 35.1




[e.g. Local Court]


[e.g. Small Claims Division


[court location]

Case number


[First] plaintiff


#Second plaintiff #Number of plaintiffs (if more than two)

[First] defendant


#Second defendant #Number of defendants (if more than two)


Filed for

[name] [role of party eg plaintiff]

#Filed in relation to

[eg plaintiff's claim, (number) cross-claim]

[include only if form to be eFiled]

#Legal representative

[solicitor on record] [firm]

#Legal representative reference

[reference number]

Contact name and telephone

[name] [telephone]

Contact email

[email address]

[on separate page]






I [#say on oath #affirm]:

  1. I am the [plaintiff/role of deponent eg. director of the plaintiff] and am in a position to know the facts set out below.

  2. This affidavit is made pursuant to section 25 of the Building and Construction Industry Security of Payment Act 1999 to accompany an adjudication certificate.

  3. The adjudication certificate is for the amount of [insert full amount] and was issued by the Authorised Nominating Authority [insert name]. The adjudication certificate was issued on [insert date]

  4. As at the date of this affidavit, the defendant has not paid the plaintiff the full adjudicated amount. The amount outstanding is [insert amount].


Signature of deponent

Name of witness

Address of witness

Capacity of witness

[#Justice of the peace #Solicitor #Barrister #Commissioner for affidavits #Notary public]

And as a witness, I certify the following matters concerning the person who made this affidavit (the deponent):

  1. #I saw the face of the deponent. [OR, delete whichever option is inapplicable]

#I did not see the face of the deponent because the deponent was wearing a face covering, but I am satisfied that the deponent had a special justification for not removing the covering.1

  1. #I have known the deponent for at least 12 months. [OR, delete whichever option is inapplicable]

#I have confirmed the deponent’s identity using the following identification document:

Identification document relied on (may be original or certified copy)2

Signature of witness

Note: The deponent and witness must sign each page of the affidavit. See UCPR 35.7B.

1[ The only "special justification" for not removing a face covering is a legitimate medical reason (at April 2012).]

2[ "Identification documents" include current driver licence, proof of age card, Medicare card, credit card, Centrelink pension card, Veterans Affairs entitlement card, student identity card, citizenship certificate, birth certificate, passport or see Oaths Regulation 2011 or JP Ruling 003 - Confirming identity for NSW statutory declarations and affidavits, footnote 3.]


# - delete if not applicable

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