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Home > Your Council > Rates and Valuations > Change of Name Form (Individual)

Change of Name Form (Individual)

A separate form must be completed for each individual.

The personal information requested on this form is being collected by Council to maintain an accurate Name and Address Register. The personal information will be used solely by Council for that primary purpose or directly related purposes. The applicant understands that the personal information provided is for Council records and that they may apply to Council for access and or amendment of their information.

Your Current Details with Council

Given Name/s (In full) * (required)

Surname * (required)

Date of Birth * (required)

Home Phone * (required)

Business Phone * (required)

Mobile * (required)

Email * (required)

Residential Address * (required)

Postal Address (If different from above)

Your New Name

New Given Name/s (In full)

New Surname

Supporting Documents

You must supply copies of legal documentation before Council will alter their records.

Please select which documentation is supporting this application: * (required)

Marriage Certificate
Deed Poll Documentation
Certified copy of drivers licence

Other (Please specify)

Upload (1)

Upload (2)

Upload (3)

Upload (4)

Accounts with Council

Do you have an Aqua Energy Membership? * (required)

Do you have any outstanding/unpaid infringements? * (required)

Declaration

Name of person completing this form * (required)

Additional Comments

I have completed all required sections on this form. I declare that all the information provided on this form is true and correct and understand that it is an offence to provide false or misleading information. * (required)

Yes, I agree

I acknowledge Wellington Shire Council's Privacy Statement. * (required)

Yes, I agree

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Change of Name Form (Individual)