Hackney carriage and private hire policy - Appendix D - Statutory Declaration Format

Statutory Declaration Format

Example of statutory declaration:


I (full name) of (address)

born on the (date of birth)

at (village, town, city, province, country)

Do solemnly and sincerely declare as follows:

The name shown above is my full true name, my name has no been changed since my birth and I am not know by any other names (if a change of name has taken place full details of previous names and dates of change must be included).

I have applied for a Tax/Private Hire licence with Bassetlaw District Council and have been told that I must declare all the places where I have lived in excess of three months. The exact detail, including dates, is/are as follows:

I have provided to the council documents detailing my character. These documents are genuine documents. I declare that these documents form a true and accurate record of every conviction, caution, formal warning or arrest I have ever had anywhere. I further declare that I have not been arrested or prosecuted for any other matters.

(If that is not the case, full detail must be set out below)

I make this solemn declaration conscientiously believing the same to be true and by virtue of the provisions of the Statutory Declarations Act 1835.

Declared at (place) this (number) day of (month and year)

Before me (printed name and signature)

Solicitor or Commissioner for Oaths

Full name and address and Company stamp.



Last Updated on Thursday, December 15, 2022