Complete on-screen and print
You can complete this form on-screen using the Editable PDF functionality with Adobe Reader.
You must still print off the application and have signed where applicable by hand.
Request for Source Document
Contact Details
Website www.govt.nz/bdm
Definition: A source document is a document that contains information that was used to register a birth, death, marriage, civil
union or name change. Source documents may not be available for all registrations, especially those before 1960.
Provide accurate and complete details to help us search
Document type:
Birth
Death
Marriage
Civil union
Name change
Subject's full names
If a marriage or civil union: Other parties full names
Date of event (or year of event)
If name change enter date of birth
Place of event (town/city) if known
The reason I am requesting the document is because:
I am the subject of the information (refer Note 1).
I am the parent or guardian of the subject of the information, who is under 18 and has not earlier married or
entered into a civil union or de facto relationship (refer Note 1).
I have been granted a power of attorney or have been given written authority by the subject of the information,
who is 18 years or older, or has earlier married or entered into a civil union or de facto relationship (refer Note 1).
Include a copy of the power of attorney or written authority.
The source document is required for the maintenance of the accuracy of the registered information. State your
reasons why below.
The source document is required for a purpose consistent with the purpose of recording the information under
the Births, Deaths, Marriages, and Relationships Registration Act 1995 that cannot be met by obtaining a
certificate or print-out. State your reasons why below.
State reasons, if required. You can also use this field to provide us with additional information:
Note 1: Applies to birth, marriage, civil union, or name change information.
My contact details
Name
Flat no
Street no
Street
Suburb or rural locality
City, town or district
Postcode
Country (if not New Zealand)
Email address
Best phone number
Complete on-screen and print
You can complete this form on-screen using the Editable PDF functionality with Adobe Reader.
You must still print off the application and have signed where applicable by hand.
Payment details
Fee ($25.00 each)
Courier fee (optional)
$25.00
To a New Zealand address $5
To a New Zealand address $5.
Courier fee (optional)
Contact us for overseas courier fees.
To an overseas address (number in brackets is
estimated delivery in working days)
Total fee
$25.00
Select a country
Complete payment details on
last page attached to this form.
My declaration (the person ordering the document must complete)
Surname
First names
Surname at birth (if different from above)
First names at birth (if different from above)
Place of birth (town or city) including country if not New Zealand
Date of birth
I declare that the information about me that is entered on this form is true and correct
Signature
Date signed
If ordering on behalf of a company state their name below and include an original signed request on letterhead
Your details or the company name will be entered in the Access Register. For information about the Access Register visit www.govt.nz/bdm
Referee’s declaration (must be completed by another person who is 16 years of age or older)
I have known the orderer for at least 6 months or have seen a government issued photo identification of the orderer
and I am 16 years of age or older – I am satisfied the information about the orderer’s identity stated in this form is true
and correct
Signature of referee
Date signed
Full name of referee
Phone number of referee
Contact address of referee
Send with fee to:
Post to Births, Deaths and Marriages, PO Box 10526, Wellington 6143, New Zealand
Privacy Statement: The information on this form is collected under the Births, Deaths, Marriages, and Relationships Registration Act 1995. As
part of processing your request, your identification details will be checked against other records held by Births, Deaths, Marriages and Citizenship
or other government agencies, as authorised by law.
Version 31 August 2021
Complete on-screen and print
You can complete this form on-screen using the Editable PDF functionality with Adobe Reader.
You must still print off the application and have signed where applicable by hand.
