Statutory declaration Form

Skilled Work Regional (Provisional) (Subclass 491) visa –

Sponsor declaration 491FS
Department of Home Affairs (To be used as evidence that a sponsor has undertaken their sponsorship obligations)

What this statutory declaration is about Who should use this statutory declaration?
Important – Please read this information carefully before you Only people who wish to sponsor an applicant for a Skilled Work
complete your declaration. Once you have completed your Regional (Provisional) (Subclass 491) visa should complete this
declaration we strongly advise that you keep a copy for your statutory declaration.
records. A sponsor must be:
Applicants for a Skilled Work Regional (Provisional) • 18 years old or older
(Subclass 491) visa who are not nominated by a State or Territory
• an Australian citizen, an Australian permanent resident, or an
government agency, must be sponsored.
eligible New Zealand citizen
The sponsor of an applicant for a Skilled Work Regional
• usually resident in a designated regional area
(Provisional) (Subclass 491) visa is a person who undertakes to:
• a parent
• assist the applicant(s) to the extent necessary in relation to
accommodation during the period of two years immediately • a child or step-child
following the grant of the visa if the applicants are in Australia, • a brother, sister, adoptive brother, adoptive sister, step-brother
or during the period of two years immediately following their or step-sister
first entry into Australia under that visa, if the applicant(s) • an aunt, uncle, adoptive aunt, adoptive uncle, step-aunt or
are outside Australia (this time period includes any period of step-uncle
participation by the applicant(s) in the Adult Migration English
• a nephew, niece, adoptive nephew, adoptive niece,
Program that falls within that period).
step-nephew or step-niece
• assist the applicant(s) financially, to the extent necessary,
• a grandparent, or
during the period of two years immediately following the
grant of the visa if the applicants are in Australia, or during • a first cousin.
the period of two years immediately following their first entry An eligible New Zealand citizen is a New Zealand citizen who is a
into Australia under that visa, if the applicant(s) are outside protected special category visa (SCV) holder within the meaning
Australia (this time period includes any period of participation of section 7 of the Social Security Act 1991.
by the applicant(s) in the Adult Migration English Program Details regarding designated regional areas of Australia are
that falls within that period). available on the Department’s website at
• accept responsibility for all financial obligations to the https://immi.homeaffairs.gov.au/visas/working-in-
Commonwealth incurred by the applicant(s) that arise out of australia/skill-occupation-list/regional-postcodes
their stay in Australia. Details about how to complete the statutory declaration and
• accept responsibility for compliance by the applicant(s) what is acceptable judicial and non-judicial evidence are
with all relevant legislation and awards in relation to any described on page 2 of this form.
employment entered into by the applicant(s) in Australia.
• accept responsibility for compliance by the applicant(s) with Important information about privacy
the conditions under which they are allowed to enter Australia Your personal information is protected by law, including the
(unless the Minister decides otherwise). Privacy Act 1988. Important information about the collection,
The sponsor undertakes these obligations by completing this use and disclosure (to other agencies and third parties, including
statutory declaration. overseas entities) of your personal information, including
Each member of the family unit of the applicant who is also an sensitive information, is contained in form 1442i Privacy notice.
applicant for a Skilled Work Regional (Provisional) (Subclass 491) Form 1442i is available from the Department’s website
visa must be sponsored by the sponsor. www.homeaffairs.gov.au/about/corporate/information/
forms or offices of the Department. You should ensure that you
read and understand form 1442i before completing this form.

This statutory declaration

This statutory declaration should be completed by the person
who wishes to sponsor an applicant(s) for a Skilled Work
Regional (Provisional) (Subclass 491) visa.
The person who wishes to sponsor an applicant(s) must
complete Parts A, B and C of the statutory declaration and then
sign Part D in front of a witness as described on page 1 and 2 of
this form.
The completed statutory declaration should be given to the
applicant to submit to the Department. The applicant can submit
the statutory declaration to the Department via their
ImmiAccount.

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Who can witness the statutory declaration?
In Australia, statutory declarations must be witnessed by a person
prescribed by the Statutory Declarations Act 1959 and Statutory
Declarations Regulations 2018. Any attachments to the
Declaration must be certified by a prescribed person.
Any attachments to the Declaration must be certified by a
prescribed person.
Prescribed persons include those who are a:
• Justice of the Peace;
• medical practitioner;
• legal practitioner;
• marriage celebrant or registered minister of religion;
• dentist;
• nurse;
• optometrist;
• pharmacist;
• migration agent registered under Division 3 of Part 3 of the
Migration Act 1958;
• teacher employed on a permanent full-time or part-time basis
at a school or tertiary education institution;
• bank officer with 5 or more continuous years of service;
• permanent employee of the Australian Postal Corporation with
5 or more continuous years of service;
• police officer; or
• public servant with 5 or more continuous years of service.
A full list of prescribed persons can be found in the Statutory
Declarations Regulations 2018, which is available through the
Attorney General’s Department website
www.ag.gov.au/publications/pages/statutorydeclarations.
aspx
A blank statutory declaration form is also available from the same
website.
Warning
Under the Statutory Declarations Act 1959, a person who
intentionally makes a false statement in a statutory declaration
can be liable for imprisonment for 4 years. In addition, the
Migration Act 1958 provides penalties for providing false or
misleading statements of 12 months imprisonment or a fine of
AUD12,000.

Home page www.homeaffairs.gov.au

General Telephone 131 881 during business hours
enquiry line in Australia to speak to an operator (recorded
information available outside these hours).
If you are outside Australia, please contact
your nearest Australian mission.

Please keep these information pages for your reference

491FS (Design date 01/20) - Page 2 © COMMONWEALTH OF AUSTRALIA, 2020
 Statutory declaration Form
Skilled Work Regional (Provisional) (Subclass 491) visa –
Sponsor declaration 491FS
Department of Home Affairs (To be used as evidence that a sponsor has undertaken their sponsorship obligations)

Please open this form using Adobe Acrobat Reader. Office use only
Either type (in English) in the fields provided or print this form
and complete it (in English) using a pen and BLOCK LETTERS. File number
Tick where applicable 3

Before completing this declaration Part A – Eligibility to be a sponsor

Please ensure that you have read the explanatory notes that accompany
this statutory declaration. 1 Your eligibility
I am an Australian citizen, an Australian permanent resident or an
Details of person making the statutory declaration eligible New Zealand citizen who is aged 18 years or older.
I, family name I am usually resident in a designated regional area at the address
provided.
given names
I am related to the applicant(s) for a Skilled Work Regional
of, residential address (Provisional) (Subclass 491) visa listed in Part B as follows:
–– a parent;
–– a child or step-child;
–– a brother, sister, adoptive brother, adoptive sister, step-brother
Postcode
or step-sister;
occupation or qualification –– an aunt, uncle, adoptive aunt, adoptive uncle, step-aunt or
step-uncle;
–– a nephew, niece, adoptive nephew, adoptive niece, step-
telephone number or daytime contact nephew or step-niece;
Area code Number
–– a grandparent, or
office hours ( )
–– a first cousin.
mobile/cell I agree to sponsor the applicant(s) for a Skilled Work Regional
(Provisional) (Subclass 491) visa listed in Part B.
make the following declaration under the Statutory Declaration Act 1959.

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 Part B – Visa applicant details 6. Family name

2 Give the following details about the person or people you are related to Given names
and that you are sponsoring. Day Month Year
1. Family name Date of birth

Given names Your relationship to the visa applicant

Day Month Year

Date of birth
7. Family name
Your relationship to the visa applicant
(i.e. parent, child or step-child, brother, sister, adoptive brother, Given names
adoptive sister, step-brother or step-sister, aunt, uncle, adoptive
aunt, adoptive uncle, step-aunt or step-uncle, nephew, niece, Day Month Year
adoptive nephew, adoptive niece, step-nephew or step-niece, Date of birth
grandparent; or first cousin)
Your relationship to the visa applicant

2. Family name
8. Family name
Given names
Given names
Day Month Year
Day Month Year
Date of birth
Date of birth
Your relationship to the visa applicant
Your relationship to the visa applicant

3. Family name

Given names
Day Month Year

Date of birth
Your relationship to the visa applicant

4. Family name

Given names
Day Month Year

Date of birth
Your relationship to the visa applicant

5. Family name

Given names
Day Month Year

Date of birth
Your relationship to the visa applicant

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 Part C – Sponsorship obligations Part D – Declaration
3 In respect of the applicant(s) for a Skilled Work Regional (Provisional) 4 I declare that:
(Subclass 491) visa listed in Part B above, I undertake to do the • I understand that a person who intentionally makes a false statement
following: in a statutory declaration is guilty of an offence under section 11 of
• assist the applicant(s) to the extent necessary in relation to the Statutory Declaration Act 1959, and I believe that the statements
accommodation during the period of two years immediately following in this declaration are true in every particular;
the grant of the visa if the applicants are in Australia, or during the • I have read the information contained in form 1442i Privacy notice;
period of two years immediately following their first entry into
• I understand the Department may collect, use and disclose my
Australia under that visa, if the applicant(s) are outside Australia (this
personal information (including biometric information and other
time period includes any period of participation by the applicant(s) in
sensitive information) as outlined in form 1442i Privacy notice.
the Adult Migration English Program that falls within that period).
• assist the applicant(s) financially, to the extent necessary, during the
period of two years immediately following the grant of the visa if the Your
signature
applicants are in Australia, or during the period of two years
immediately following their first entry into Australia under that visa, if
-
the applicant(s) are outside Australia (this time period includes any Declared at
period of participation by the applicant(s) in the Adult Migration Day Month Year
English Program that falls within that period) .
on
• accept responsibility for all financial obligations to the
Commonwealth incurred by the applicant(s) that arise out of their Before me,
stay in Australia.
• accept responsibility for compliance by the applicant(s) with all Signature of
relevant legislation and awards in relation to any employment prescribed
entered into by the applicant(s) in Australia. person -
• accept responsibility for compliance by the applicant(s) with the Day Month Year
conditions under which they are allowed to enter Australia (unless on
the Minister decides otherwise).
I acknowledge that, among other things, the Department must 5 Details of person before whom the declaration is made
accept my sponsorship before the applicant(s) listed in Part C can
be granted a Skilled Work Regional (Provisional) (Subclass 491) Preferred title: Mr Mrs Miss Ms Other
visa.
Family name

Given names
Contact address

Postcode

Occupation or qualification

Telephone number
Office hours (Area code )

We strongly advise that you keep a copy of your application

and all attachments for your records.

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