NSW Domestic Violence Disclosure Scheme Application for someone I am concerned about to receive information

What is the Domestic Violence How does the Scheme work? Take care when completing this Disclosure Scheme? You will need to complete this application as it is an offence The NSW Domestic Violence application form and submit it to a to provide false or misleading Disclosure Scheme helps people police station in a participating local information in an application, and who may be at risk of domestic area command where the person penalties apply. violence to find out if their current at risk lives. Police will review this What information will be or former partner has a history of application and do a criminal record disclosed? violent criminal offences. check on the current or former partner. A conviction will be disclosed to the How can the Scheme help prevent person who may be at risk where Even where the application is domestic violence? the subject of the application (i.e. made by a third party, the the current or former partner) has Domestic violence is usually disclosure is made to the person a relevant offence in their criminal characterised by a pattern of who may be at risk, unless there history. abusive and controlling behaviours, are exceptional circumstances and perpetrators often repeat determined by police. Relevant convictions are for these behaviours in successive personal violence offences You may be present at the relationships. The pilot Scheme committed within a domestic disclosure only where the person aims to prevent domestic violence relationship. These include: who may be at risk invites you to be from occurring by empowering there as a support person. those who may be at risk to make • Most personal violence offences such as murder, manslaughter, informed decisions about their Will their current/former partner physical and sexual assault, relationship. know that an application or a property damage disclosure was made? Where is the Scheme available? • Stalking and intimidation To ensure the safety of those who The Scheme is being piloted in may be at risk, the subject of the • Breaches of an Apprehended four NSW Police Force Local Area application (i.e. a current or former Domestic Violence Order. Commands: partner) will not be informed of Other relevant convictions include • Oxley (Tamworth region) any application or disclosure made certain personal violence offences • Shoalhaven (Nowra region) about them. committed outside of a domestic relationship: • Sutherland Can I make an application? (Menai/Engadine/Sutherland As a third party you must be • Sexual offences region) a family member, friend or a • Child abuse offences • St George professional who has an ongoing • Murder (Kogarah/Hurstville region) relationship with the person who may be at risk. To apply, you and the person who If a relevant conviction exists, the may be at risk need to be aged To apply, you and the person who person you are applying for will be 16 years and over. The person may be at risk need to be aged told the type of offence and the you are applying for must live in a 16 years and over. The person date of the conviction. The police participating local area command. you are applying for must live in a may also consider telling them A list of relevant suburbs and participating local area command. additional information, such as the postcodes is provided on page 7. You will need to complete and relationship between their current submit this application form at a or former partner and the victim of police station in the pilot region the offence. This will be considered where the person who may be at on a case-by-case basis because risk lives. police must be careful not to identify those victims.

NSW Domestic Violence Disclosure Scheme · PAGE 1 Some offences and orders will not What support services will be What is an intimate relationship? be disclosed under the Scheme. available to the person I am For the purpose of the Scheme, These include: applying for? an intimate relationship includes A worker from a specialist domestic people who are married or engaged • Offences committed outside violence support service will be to be married, separated, divorced, NSW present at the disclosure to provide de facto partners, couples promised • Offences where no conviction support and help plan for their to each other under cultural or was recorded safety. religious tradition, or who are • Convictions that have become The support service may also dating. It may or may not involve spent arrange other help such as a sexual relationship and may be • Juvenile convictions translation services, trauma between people of the same or • Apprehended Domestic Violence counselling and other specialist different sex. Orders (these civil orders are not support as required. For former relationships, there must recorded on criminal histories) The person at risk may bring their be evidence of ongoing contact own support person, such as a between the person at risk and How long does it take to get a friend, relative or professional their current or former partner. This disclosure? working with them or their family. means contact that is consistent or After you have submitted your planned, and may include: application, police will assess Will I receive the disclosure? • Family Court proceedings whether there is a serious threat The disclosure will only be made in • child care arrangements to the life, health or safety of the person to the person who may be • family functions person you are applying for by at risk, unless there are exceptional doing a risk assessment of their circumstances. You may be present • mutual friends or social networks circumstances, and a criminal at the disclosure only where the • common dealing in private record check their current or former person who may be at risk invites property or business partner. you to be there as a support person. • common dealing or use of a The police will process all residence Will I be informed of the applications within two weeks. If • work or a common employer the police believe there is a serious outcome of my application? • common kinship relationships in threat to the person you are No, the police will make contact Aboriginal communities, or applying for, they will be notified of with the person who may be at risk. any relevant convictions within • living in small rural communities 48 hours. What happens if there are no where contact is unavoidable. relevant convictions? What will happen at the Where can I get more information? A support service worker will be disclosure? More information is available at available to offer support and to www.domesticviolence.nsw.gov.au/ The police will advise the person further discuss any relationship dvds. who may be at risk in person at concerns. the police station or at another Generally, domestic violence safe location. A domestic violence is under-reported, and some support service will be present to matters are withdrawn before they provide support and help plan for are finalised at court so not all their safety. perpetrators of domestic violence Any person present at a disclosure will have a criminal conviction. will be required to sign a legal The absence of a relevant criminal document stating that they will not conviction does not mean that the misuse any information disclosed. person is not at risk of domestic This means that any person who violence, and it is important that receives information must agree you report any future concerns or to not publish or spread the instances of violence to the police. information, or use the information to stalk or intimidate their current or former partner, or embarrass or humiliate them on social media or through other public networks.

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Office use only: Application form COPS Event number NSW Domestic Violence Disclosure Scheme

PART 1: PART 2: Personal details of the person who may be at risk Details of children

1. Their full name 13. Do they have children?

Title (e.g. Mr, Mrs, Miss, Ms) Yes No (if no, please move to question 14) Surname Please list the names of children who live most or all of the time with the person who may be at risk. First name Child 1 Middle name Surname 2. Have they been known by another name? (please insert) First name Middle name Gender Female Male Other 3. Their gender (please select) Female Male Other Date of birth dd / mm / yyyy 4. Their address Address (only if different from person at risk)

Street address Suburb

Postcode Child 2 Postal address (if different) Surname First name Middle name Gender Female Male Other 5. Their contact details (for police to contact them) Date of birth dd / mm / yyyy Home phone Address (only if different from person at risk) Mobile Email address

6. Their date of birth (dd/mm/yyyy) Child 3 dd / mm / yyyy Surname First name 7. Preferred method and time for police to contact them Middle name Gender Female Male Other 8. Have they made an application before? Date of birth dd / mm / yyyy No Yes Unsure Address (only if different from person at risk)

Police station dd mm yyyy

Date / / Child 4 9. Their preferred language (optional) Surname First name 10. Do they need an interpreter? (optional) No Yes Middle name 11. Are they of Aboriginal or Torres Strait Islander origin? Gender Female Male Other (optional) dd mm yyyy Date of birth / / No Yes, Aboriginal Yes, Torres Strait Islander Address (only if different from person at risk)

12. Do they have a disability? No Yes

NSW Domestic Violence Disclosure Scheme · PAGE 3 Child 5 18. Your contact details Surname Home phone First name Mobile Middle name Email address Gender Female Male Other dd mm yyyy Date of birth / / 19. Why are you making an application on behalf of the person who may be at risk? Address (only if different from person at risk)

Child 6 20. Are they aware that you are making an application? Surname Yes No First name Middle name 21. If no, please explain why you have not told them Gender Female Male Other Date of birth dd / mm / yyyy Address (only if different from person at risk)

PART 4: The details of the person’s current or former partner

PART 3: 22. Their full name Your Details Title (e.g. Mr, Mrs, Miss, Ms) Note: You can only make an application if you have some Surname form of ongoing contact with the person who may be at risk. First name For example, you are a parent or guardian, relative, friend, or professional working with the person at risk or their family. Middle name The disclosure will only be made in person to the person who may be at risk. It is important that you continue to be in 23. Have they been or are they known by another name? (please insert) contact with the person you are applying for and help them to consider their options to ensure their safety.

14. Your relationship to the person who may be at risk 24. Their gender (please select) Female Male Other Parent/guardian Friend/family member 25. Their address Professional* Other* Street address * Please specify Suburb 15. Your full name Postcode Title (Mr, Mrs, Miss, Ms) Postal address (if different) Surname First name

Middle name 26. Their contact details

16. Name of the organisation where you work (if applicable) Home phone Mobile

17. Your address Email address

27. Their date of birth dd / mm / yyyy Postal address (if different) 28. Their relationship to the person who may be at risk Current partner Former partner

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PART 5: PART 6: Reason for making the application Applicant’s declaration

29. Is the person who may be at risk still in the relationship? There are penalties for including false or misleading information No Yes Unsure in your application, and requires that you make a declaration that the information you provide is correct and true. This is outlined in 30. How long has/was the person who may be at risk been in section 307A of the Crimes Act 1900, which reads: the relationship? Crimes Act 1900

Years 307A False or misleading applications (1) A person is guilty of an offence if: Months (a) the person makes a statement (whether orally, in a document or in any other way), and 31. Does the person who may be at risk live with their (b) the person does so knowing that, or reckless as to current/former partner? whether, the statement: (i) is false or misleading, or No Yes Sometimes (ii) omits any matter or thing without which the statement is misleading, and 32. Describe the nature of their relationship. (c) the statement is made in connection with an application for an authority or benefit, and (d) any of the following subparagraphs apply: (i) the statement is made to a public authority, (ii) the statement is made to a person who is exercising or performing any power, authority, duty or function under, or in connection with, a law of the State, 33. For former relationships only: Describe the nature (iii) the statement is made in compliance or purported of ongoing contact between the person and their compliance with a law of the State. current/former partner Maximum penalty: Imprisonment for 2 years, or a fine of 200 penalty units, or both.

I hereby apply for information to be disclosed under the NSW Domestic Violence Disclosure Scheme. I am aware that it is an offence to knowingly or recklessly provide 34. Are there current Family Law Court proceedings? false or misleading information in the application form.

No Yes Unknown Applicant name

35. Are there Family Law Court orders? Applicant signature No Yes Unknown Date / /

36. Is there, or has there been, an Apprehended Domestic Name of NSW Police Force officer and registration number Violence Order between the person and their current/ former partner? Signature of NSW Police Force officer No Yes Unknown

If yes, when? Date / / 37. What are the concerns or reasons for you making this application? PART 7: Proof of identity

You must satisfy the identity check requirement (minimum 100 points) and bring your original identification to the police station with you. The table on the following page lists the approved identification documents and points value. How did you hear about the Scheme? (Optional) Office use only: 100 points of ID verified? Yes No, (application cannot be processed) Primary person resides in pilot LAC? Yes No, (application cannot be processed)

Further information

You can submit an application 24 hours a day, seven days a week at a participating police station in NSW. A list of participating suburbs is on page 7. For more information, contact your nearest police station or visit www.domesticviolence.nsw.gov.au/dvds NSW Domestic Violence Disclosure Scheme · PAGE 5 Proof of identity

Document details Document type The table below provides a list of approved documents for establishing proof of identity. and point value Copies of these documents must be certified by a Justice of the Peace or serving police officer Document • Birth certificate • Birth card issued by the Registry of Births, Deaths and Marriages • Citizenship certificate Primary documents • Current passport 70 points • Expired passport which has not been cancelled and was current within the preceding two years • Other document of identity having the same characteristics as a passport including diplomatic documents and some documents issued to refugees Document - must have a photograph and a name • Driver licence issued by an Australian State or Territory • Roads and Maritime Services (formerly RTA) photo card • Licence or permit issued under a law of the Commonwealth, a State or Territory Government Secondary documents (eg a boat licence) 40 points • Identification card issued to a public employee • Identification card issued by the Commonwealth, a State or Territory Government as evidence of the person’s entitlement to a financial benefit • An identification card issued to a student at a tertiary education institution Document - must have name and address on • A document held by a cash dealer giving security over your property • A mortgage or other instrument of security held by a financial body 35 points • Council rates notice • Document from your current employer or previous employer within the last two years • Land Titles Office record • Document from the Credit Reference Association of Document - must have name and signature on • Marriage certificate (for maiden name only) • Credit card 25 points • Foreign driver licence • Medicare card (signature not required on Medicare card) • EFTPOS card Document - must have name and address on • Records of a public utility, eg phone, water, gas or electricity bill • Records of a financial institution 25 points • Electoral roll compiled by the Australian Electoral Commission and available for public scrutiny • A record held under a law other than a law relating to land titles • Lease/rent agreement • Rent receipt from a licensed real estate agent Document - must have name and date of birth on • Record of a primary, secondary or tertiary education institution attended by you within the last 25 points 10 years • Record of professional or trade association of which you are a member Person under the age A child will meet the 100-point requirement if his or her Identity is verified from ONE of the of 18 following: • Birth Certificate/Birth Extract • Australian Passport (current, or expired within the previous two years, but not cancelled) • Australian Citizenship certificate • International Passport (current, or expired within the previous two years, but not cancelled) • Other document of identity having same characteristics as a passport eg. diplomatic/refugee • Photo or Signature • A statement from an educational institution, signed by the principal or deputy principal, confirming that the child attends the institution (statement must be on the institution’s letterhead).

NSW Domestic Violence Disclosure Scheme · PAGE 6 List of postcodes covered by participating local area commands (LAC)

Tamworth – Oxley Nowendoc 2354 Bomaderry 2541 Nowra 2541 Lucas Heights 2234 LAC covers: Nundle 2340 Boolijah 2540 2540 Maianbar 2230 Appleby 2340 Ogunbil 2340 2540 Numbaa 2540 Menai 2234 Attunga 2345 Orange Grove 2380 Brogers Creek 2535 Old 2540 Oyster Bay 2225 Banoon 2347 Oxley Vale 2340 Brooman 2538 Orient Point 2540 Royal National Park 0 Barraba 2347 Piallamore 2340 Broughton 2535 Parma 2540 Sandy Point 2172 Bective 2340 Piallaway 2342 2535 Pebbly Beach 2536 Sutherland 2232 Bendemeer 2355 Pine Ridge 2343 Browns Mountain 2540 Pointer Mountain 2539 Sylvania 2224 Bithramere 2340 Premer 2381 2540 Porters Creek 2538 Waterfall 2233 Blackville 2343 Quipolly 2343 Buangla 2540 Pretty Beach 2539 Woronora 2232 Blue Vale 2380 Quirindi 2343 Budawang 2622 2540 Woronora Dam 2508 Borah Creek 2346 Rangari 2380 Budgong 2577 Quiera 2622 Woronora Heights 2233 Borambil 2329 Red Hill 2347 Bulee 2622 Red Rocks 2577 Yarrawarrah 2233 Bowling Alley Point 2340 Retreat 2355 2535 2540 Braefield 2339 Rushes Creek 2346 Burrier 2540 Sassafras 2622 Kogarah/Hurstville – Breeza 2381 Somerton 2340 2539 2535 St George LAC covers: Bundarra 2359 South Tamworth 2340 2540 2541 Allawah 2218 Bundella 2343 Spring Ridge 2343 2540 St George 2622 Arncliffe 2205 Calala 2340 Tambar Springs 2381 Cambewarra 2540 St Georges Basin 2540 Banksia 2216 Caroona 2343 Taminda 2340 2540 Sussex Inlet 2540 Bardwell Park 2207 Carroll 2340 Tamworth 2340 Cockwhy 2539 Swanhaven 2540 Bardwell Valley 2207 Cobbadah 2347 The Pilliga 2388 Comberton 2540 Tallowal 2540 Beverley Park 2217 Colly Blue 2343 Thirldene 2347 Comerong Island 2540 Tapitallee 2540 Beverly Hills 2209 Coomoo Coomoo 2343 Timbumburi 2340 Conjola 2539 2540 Bexley 2207 Crawney 2338 Tintinhull 2352 2539 2539 Bexley North 2207 Curlewis 2381 Upper Horton 2347 Coolangatta 2535 2622 Blakehurst 2221 Currabubula 2342 Upper Manilla 2346 2622 Tolwong 2622 Brighton-Le-Sands 2216 Daruka 2340 Walcha 2354 Croobyar 2539 2540 Carlton 2218 Duncans Creek 2340 Walcha Road 2354 2540 Touga 2622 Carss Park 2221 Dungowan 2340 Wallabadah 2343 2540 Tullarwalla 2540 Connells Point 2221 Duri 2344 Wallamore 2340 2539 Twelve Mile Peg 2540 Dolls Point 2219 East Tamworth 2340 Warrabah 2346 Currarong 2540 Ulladulla 2539 Hurstville 2220 Emerald Hill 2380 Warrah Ridge 2343 Currowan 2536 2577 Hurstville Grove 2220 Garoo 2340 Warral 2340 2539 Vincentia 2540 Kingsgrove 2208 Garthowen 2345 Watsons Creek 2355 2536 Wandandian 2540 Kogarah 2217 Ghoolendaadi 2380 Weabonga 2340 East Lynne 2536 Watersleigh 2540 Kogarah Bay 2217 Gidley 2340 Werris Creek 2341 Endrick 2622 Wattamolla 2535 Kyeemagh 2216 Goolhi 2379 West Tamworth 2340 Erowal Bay 2540 2541 Kyle Bay 2221 Goonoo Goonoo 2340 Westdale 2340 Ettrema 2540 Wollumboola 2540 Lugarno 2210 Gowrie 2340 Willala 2382 Falls Creek 2540 Woodburn 2538 Mortdale 2223 Gulf Creek 2347 Willow Tree 2339 Far Meadow 2535 Woodhill 2535 Narwee 2209 Gundamulda 2347 Wimborne 2346 Fishermans Paradise 2539 Woodstock 2538 Monterey 2217 Gunnedah 2380 Winton 2344 2540 2540 Oatley 2223 Halls Creek 2346 Wongo Creek 2346 Huskisson 2540 2540 Peakhurst 2210 Hallsville 2340 Woodsreef 2347 Hyams Beach 2540 2540 Peakhurst Heights 2210 Hanging Rock 2340 Woolbrook 2354 Illaroo 2540 2540 Penshurst 2222 Hillvue 2340 Woolomin 2340 2535 Yadboro 2539 Riverwood 2210 Ironbark 2347 Yannergee 2343 2540 2540 Ramsgate 2217 Keepit 2340 Yarraman 2400 Kangaroo Valley 2577 Yatte Yattah 2539 Ramsgate Beach 2217 Kelvin 2380 Yarrowitch 2354 Kinghorne 2540 2540 Rockdale 2216 Kentucky 2354 Kings Point 2539 Sandringham 2219 Kingswood 2340 Nowra – Shoalhaven Kioloa 2539 Sutherland – Sutherland Sans Souci 2219 Klori 2346 LAC covers: 2539 LAC covers: South Hurstville 2221 Kootingal 2352 Back Forest 2535 Lake Tabourie 2539 Alfords Point 2234 Turrella 2205 Limbri 2352 Bamarang 2540 Little Forest 2538 Bangor 2234 Wolli Creek 2205 Lindesay 2347 Bangalee 2541 Longreach 2540 Barden Ridge 2234 Longarm 2347 Barren Grounds 2577 2539 Bonnet Bay 2226 A full list of local area Loomberah 2340 Barrengarry 2577 Mayfield 2540 Bundeena 2230 commands and police Manilla 2346 Barringella 2540 2540 Como 2226 stations are available on the Marys Mount 2380 2540 Milton 2538 Engadine 2233 NSW Police website Mayvale 2347 2539 Mogood 2538 Grays Point 2232 www.police.nsw.gov.au Milroy 2380 Beaumont 2577 2539 Gymea 2227 Moonbi 2353 2540 Mollymook Beach 2539 Gymea Bay 2227 Moore Creek 2340 2535 Mondayong 2540 Heathcote 2233 Mulla Creek 2352 2539 Moollattoo 2540 Holsworthy 2173 Mullaley 2379 2540 Morton 2538 Illawong 2234 Namoi River 2346 2539 Mount Kingiman 2539 Jannali 2226 Nemingha 2340 Berry 2535 Mundamia 2540 Kangaroo Point 2224 New Mexico 2346 Berry Mountain 2535 Myola 2540 Kareela 2232 April 2016 (C) NSW Health. Niangala 2354 Bewong 2540 2539 Kirrawee 2232 SHPN (WNSW) 160134. North Tamworth 2340 Bolong 2540 2541 Loftus 2232 ISBN 978-1-76000-408-8.

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