No. 41970   43 STAATSKOERANT, 12 OKTOBER 2018 B0000000001 A4. ACKNOWLEDGEMENT OF PATERNITY OF A CHILD I hereby declare that I am the biological father of the child Mother’s consent to the acknowledgement of paternity Initials and surname Signature Initials and surname ID No./ Passport No./ PR/ Refugee/ Asylum Seeker No. Date Y Y Y Signature ID No./ Passport No./ PR/ Refugee/ Asylum Seeker No. Y M M M M M M M M M D D Date Y Y Y Y M M M M M M M M M D D NOTE: The palm, foot or fingerprints of the child must be taken and affixed below by an official of the Department. LEFT RIGHT A5. PARTICULARS OF A PERSON WHO WITNESSED THE BIRTH (for a birth that occurred at a place other than a Health Facility) Date of birth Y Y Y Y M M M M M M M M M D Left thumbprint of Witness ID No./ Passport No./ PR/ Refugee/ Asylum Seeker No. D Surname Previous/Maiden surname Forenames in full Physical address Street Postal code Town/Village Province Telephone no., incl. area code Cell phone no. E-mail address Relationship to Mother/Parent A NOTE: Attach online verification print out of witness. If not RSA citizen, attach fingerprint form. DECLARATION BY PERSON WHO WITNESSED THE BIRTH I, ____________________________________________________________________, whose particulars appear in Part A above, hereby declare that the information supplied in this application is to the best of my knowledge and belief, true and correct. I understand that any false statement made in this application and supporting documents is an offence and punishable in terms of section 31 of the Births and Deaths Registration Act of 1992. WITNESS Date Initials and surname Y Y Y Y M M Place Signature Page 3 of 10 This gazette is also available free online at www.gpwonline.co.za M M M M M M M D D