No. 41970   57 STAATSKOERANT, 12 OKTOBER 2018 L0000000001 A10. FOR OFFICIAL USE ONLY - OFFICE OF ORIGIN Office stamp - Office of Origin APPLICATION RECEIVED AND VERIFIED BY: Initials and surname Signature Date Y Y Y Y M M M M M M M M M D D Identity number User ID Stat I Birth O S M DOCUMENTS SUBMITTED WITH THIS APPLICATION: PLEASE TICK þ Proof of Birth Form (DHA-24/PB) Each page of Affidavit is initialled by informant and Commissioner of Oaths Certified copy of Applicant’s ID DHA-24/A for the Applicant Certified copy of the Foreign birth certificate of the child Certified copy of court order (abandoned/orphaned children) / Legal guardian Copy of Foreign birth certificate Citizenship determination Form DHA-529 (SA Parent) Certified copy of death certificate (if applicable) Original ID document of informant was presented Citizenship determination Form DHA-529 (Child) Certified copy of court order (abandoned/orphaned children) / Legal guardian Marriage certificate of the parents (copy) Certified copy of death certificate (if applicable) Certified copy of Social Worker’s Registration Certificate Online verification performed and printouts attached for following persons: Mother (Parent A) Father (Parent B) Applicant Person whose birth is sought to be registered Next of Kin Person who witnessed birth Please enter the barcode numbers of the fingerprint verification forms: (DHA-24/A) of the Applicant: A11. VERIFIED BY SUPERVISOR - OFFICE OF ORIGIN: Initials and surname Signature Persal Number Date Y Y Y Y M M M M M M M M M D D Application is complete and all required documents are attached Fingerprints are taken correctly Person whose birth is sought to be registered A12. FOR OFFICIAL USE ONLY Capturing date Y Y RESERVED FOR THE SECTION THAT ALLOCATES THE ID NUMBER Y Y M M M M M M M M M Initials and surname D Office stamp D FOR OFFICE WHERE ID NUMBER WAS CAPTURED Signature Persal Number PART B B. DETAILS OF LIFE EVENTS OF THE CHILD B1. INSTITUTION OF BIRTH - COMPULSORY Place of birth Public hospital Private hospital Doctor’s office At home Clinic Other Name of place of birth Full address Street Town/Village Province Telephone no., incl. area code Cell phone no. Postal code E-mail address Contact person’s name and surname B2. RELIGIOUS CEREMONY PERFORMED ON THE CHILD / PERSON TO BE REGISTERED Institution name Contact address Street Town/Village Province Telephone no., incl. area code Cell phone no. Postal code E-mail address Contact person’s name and surname Date of ceremony (YYYYMMDD) Y Y Y Y M M M M M M M M M D D Type of ceremony Page 5 of 9 This gazette is also available free online at www.gpwonline.co.za