48   No. 41970 GOVERNMENT GAZETTE, 12 OCTOBER 2018 B0000000001 PART F: VERIFICATION, SUPPLEMENTATION OR RECTIFICATION OF PERSONAL PARTICULARS [Section 7(2) of the Births and Deaths Registration Act 51, 1992] THIS APPLICATION IS FOR MYSELF OR FOR MY MINOR CHILD I HEREBY APPLY TO VERIFY, SUPPLEMENT OR RECTIFY THE FOLLOWING PARTICULARS: (please tick þ) Surname Rectification Rectification of sex description Date of birth Rectification Alteration of sex description (in terms of Act 49 of 2003) (Only write reasons for change below) False registration (particulars of incorrect parents recorded on the birth register) Parents’ particulars Forename Rectification Place of birth Rectification Amplification of birth Registration REASON FOR CHANGING THE PARTICULARS Briefly give your reasons for application. You may not write one word explanations like “personal” or “professional”. If you do, your application cannot be processed. Note: Your reason is taken into account when considering your application. You will be requested to provide documentation to substantiate your reason. CURRENT PARTICULARS OF APPLICANT Identity number Date of birth Y Y Y Y M M M M M M M M M D D Surname Forenames (in full) Place of birth Residential address: Street Town / Village Code Telephone no., incl. area code Cell phone Province E-mail address The particulars are erroneously recorded as: The correct particulars must be as follows: These correct particulars must be reflected in the Birth Register and/or Identity Document. DECLARATION I, .................................................................................................................................. (the applicant), hereby declare under oath that the information submitted is to the best of my knowledge and belief true and correct in case it is not true, I shall be guilty of an offence and on conviction liable to a fine or imprisonment for a period not exceeding five years of to both such fine and such imprisonment (Section 31(1)(b) of Act 51 of 1992) Signature of deponent Date signed Y Y Y Y M M M M M M M M M D D 1. I certify that before administering the oath / affirmation I asked the deponent the following questions and wrote down his / her answers in his / her presence: 1.1 Do you know and understand the contents of this declaration? 1.2 Do you have any objection to taking the prescribed oath? 1.3 Do you consider the prescribed oath to be binding on your conscience? 2. I certify that the deponent has acknowledged that he / she knows and understands the contents of this declaration which was sworn to / affirmed before me and the deponent’s signature / thumbprint / mark was placed thereon in my presence. Surname Forenames in full Business address Street Town / Village Code Commissioner of Oaths Date signed Designation/Rank Y Y Y Y M M M M M M M M M D D Page 8 of 10 This gazette is also available free online at www.gpwonline.co.za