No. 41970   49 STAATSKOERANT, 12 OKTOBER 2018 PART G: RECORDING OF ADOPTION B0000000001 [Only for use by the adoptive parents] G1. WE ARE THE ADOPTIVE PARENTS OF THE FOLLOWING CHILD 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 We hereby apply to record the adoption of the child in *his / her birth register (*circle which is applicable). The child will assume the following name and surname after the adoption: Forenames Surname Signature of Mother / Parent A Signature of Father / Parent B G2. FOR OFFICIAL USE ONLY - OFFICE OF ORIGIN DOCUMENTS SUBMITTED WITH THIS APPLICATION: APPLICATION RECEIVED BY: PLEASE TICK þ Surname Birth certificate Forenames in full Copy of adoption order User ID Date Signature Other, specify .................................................................. Y Y Y Y M M D D Proof of payment Stamp Page 9 of 10 This gazette is also available free online at www.gpwonline.co.za