Form
Undertaking declaration 1257
Department of Home Affairs
Important – Please read this information carefully before you Please open this form using Adobe Acrobat Reader.
complete this declaration. Once you have completed this Either type in the fields provided or print this form and complete it using
declaration we strongly advise that you keep a copy for your a pen and BLOCK LETTERS.
records.
Tick where applicable 3
Who should use this form?
This form is to be completed by the person (21 years or older) Part A – Child’s/Children’s details
who has been nominated by parent(s) or legal guardian(s) to be
responsible for a child/children (under 18 years of age) who:
1 How many children are included in this undertaking?
• intend to stay in Australia; and
• whose stay will not be in the company of one, or both of 2 Give details of each child included in this undertaking
his/her parent(s) or legal guardian(s); and
Provide details as shown in passport
• who will not be staying with a relative; and
• who is not a member of an organised tour providing adequate 1. Family name
maintenance and support arrangements for their stay in
Australia. Given names
The person nominated must provide an undertaking to provide Day Month Year
accommodation and be responsible for the support and general Date of birth
welfare of the child during their stay in Australia. This
undertaking must be provided by a person who, in the belief of Passport number
the Minister, is of good character.
Transaction
The person providing the undertaking should be physically Reference Number
present in Australia for the period of the child’s/children’s
intended stay
2. Family name
Important information about privacy Given names
The Privacy Act 1988 contains 13 Australian Privacy Principles Day Month Year
which regulate the way that the Department of Home Affairs (the
Department) collects and handles personal information. Date of birth
Information about how the Department collects, uses and
discloses personal information for its key functions can be found Passport number
in form 1442i Privacy notice. More information about the Transaction
Department’s general information handling practices (including Reference Number
form 1442i) can be found in the Department’s Privacy policy at
[Link] 3. Family name
our-commitments/privacy
Given names
Day Month Year
Date of birth
Passport number
Transaction
Reference Number
4. Family name
Given names
Day Month Year
Date of birth
Passport number
Transaction
Reference Number
If insufficient space attach additional details
© COMMONWEALTH OF AUSTRALIA, 2020 1257 (Design date 10/20) - Page 1
Part B – Responsible nominee’s details 13 Details from your passport
Passport number
3 Family name
Country of passport
Day Month Year
Given names Date of issue
Date of expiry
4 Other names you are, or have been, known by Issuing authority/place of issue as shown in your passport
(including name at birth, previous married names, aliases)
14 Are you:
Indeterminate /
5 Sex Male Female Intersex / Unspecified An Australian citizen
A permanent resident in Australia Go to Question 16
Day Month Year
An eligible New Zealand citizen
6 Date of birth
A temporary resident Go to Question 15
7 Relationship status
Married Separated Never married or
15 Are you currently holding or applying for an Australian visa?
Engaged Divorced been in a de facto No
relationship Yes Give details
De facto Widowed
Visa label number
8 Current residential address V <
Visa grant number
Postcode File number (if you are applying for a visa)
9 Postal address
(if same as the residential address, write ‘as above’)
16 Employment status
Employed/ Employer/Business name
self-employed
Postcode
Address
10 Telephone numbers
Country code Area code Number
Office hours ( ) ( )
Postcode
Mobile/cell
Telephone
Country code Area code Number
11 In the course of deciding on the application, we may need to contact you
about the undertaking provided by you. ( ) ( )
Do you agree to the Department communicating with you by fax, email, Retired
or other electronic means?
Student
No
Unemployed
Yes Give details
Country code Area code Number
Other Please specify
Fax number ( ) ( )
Email address
12 Place of birth
Town/city
Country
1257 (Design date 10/20) - Page 2 © COMMONWEALTH OF AUSTRALIA, 2020
17 Have you ever: If you answered ‘Yes’ to any question at Question 17, give details,
including the date of the charge, the outcome and any penalty imposed.
• been charged with any offence that is
Also attach court documents (for example sentencing remarks or court
currently awaiting legal action? No Yes
transcripts).
• been convicted of an offence in any country Where relevant, provide a copy of all declared orders (for example, any
(including any conviction which is now domestic or family violence orders, child protection orders, or orders that
removed from official records)? No Yes prohibit the applicant from having contact with another person for their
• been charged or convicted of family or personal protection). You are only requested to declare an order where
domestic violence offences or similar related the applicant is the respondent or subject of the order. You are not asked
offences? No Yes to declare an order where the applicant is the person requiring personal
protection.
• been the subject of a domestic or family
violence order, or any other order, of a tribunal
or court or other similar authority, for the
personal protection of another person? No Yes
• been the subject of an arrest warrant or
Interpol notice? No Yes
• been found guilty of a sexually based offence
involving a child (including where no
conviction was recorded)? No Yes
• been named on a sex offender register? No Yes
• been acquitted of any offence on the grounds
of unsoundness of mind or insanity? No Yes
• been found by a court not fit to plead? No Yes
• been directly or indirectly involved in, or
associated with, activities which would
represent a risk to national security in
Australia or any other country? No Yes
• been charged with, or indicted for: genocide,
war crimes, crimes against humanity, torture,
slavery, or any other crime that is otherwise of
a serious international concern? No Yes
Part C – Undertaking declaration
• been associated with a person, group or 18 WARNING: Giving false or misleading information is a serious offence.
organisation that has been/is involved in
I declare that:
criminal conduct? No Yes
• the information supplied on this form is correct;
• been associated with an organisation engaged
• I will be residing in Australia for the period of the above
in violence or engaged in acts of violence
child’s/children’s stay;
(including war, insurgency, freedom fighting,
terrorism, protest) either overseas or in • I will ensure that the adequate accommodation is available to the
Australia? No Yes child/children during the child’s/children’s stay in Australia;
• served in a military force, police force, state • I will accept responsibility for the support and general welfare of the
sponsored/private militia or intelligence child/children named on this form;
agency (including secret police)? No Yes • I accept that I must immediately advise the Department if I become
aware that any information provided in this form is incorrect or if
• undergone any military/paramilitary training,
there is a change in my circumstances that is relevant to this
been trained in weapons/explosives or in the
undertaking at any time;
manufacture of chemical/biological products? No Yes
• I accept that the Australian Federal Police or other Commonwealth
• been involved in people smuggling or people bodies may look into my history as necessary;
trafficking offences? No Yes
• I will inform the Department in writing if I withdraw my undertaking;
• been removed, deported or excluded from any • I have read the information contained in form 1442i Privacy notice; and
country (including Australia)? No Yes
• I understand the Department may collect, use and disclose my
• overstayed a visa in any country (including personal information (including biometric information and other
Australia)? No Yes sensitive information) as outlined in form 1442i Privacy notice.
• had any outstanding debts to the Australian
Government or any public authority in Signature of
Australia? No Yes responsible
nominee -
Day Month Year
Date
We strongly advise that you keep a copy of this declaration
and all attachments for your records.
© COMMONWEALTH OF AUSTRALIA, 2020 1257 (Design date 10/20) - Page 3
