CHANGE OF NAME DEED POLL

THIS DEED OF CHANGE OF NAME is made on ________

BY

(1) ________, formerly known as, ________ of

________

BACKGROUND

(A) I have changed my name and wish to renounce my former name.

THIS DEED DECLARES as follows:

I. RELATIONSHIP STATUS

I confirm that I am single.

II. CITIZENSHIP STATUS

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III. OLD NAME

Before I changed my name to ________, my name was ________.

IV. RENUNCIATION OF OLD NAME

I absolutely renounce the use of my former name of ________ and determine to assume and use the name of ________ in its place.

V. USE OF NEW NAME IN DOCUMENTS

I declare that I shall at all times from now on in all documents, records, deeds, actions, proceedings, in all dealings and transactions and on all occasions use the name of ________ as my name in place of my former name of ________.

VI. AUTHORITY FOR THIRD PARTIES TO USE NEW NAME

I authorise and require everyone to refer to me and to address me by my new name of ________.

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SIGNED AS A DEED AND DELIVERED by ________, formerly known as, ________:

Signed:..............................................

________

formerly known as

Signed:..............................................

________

IN THE PRESENCE OF:

Signed:..............................................

Full name of witness:

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Address of witness:

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Occupation of witness:

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