No. 41970   45 STAATSKOERANT, 12 OKTOBER 2018 B0000000001 PART B: AMENDMENT OF PERSONAL DETAILS B1. Change of a surname of a Minor (Section 25 (a), (b), (c), (d) of Act,1992) I do hereby apply that his / her surname be altered to: THE REASON FOR MY APPLICATION IS AS FOLLOWS: (Please indicate with a þ the reason which is applicable) My child was born out of wedlock and I am now married to someone else other than the natural father of my child (Provide consent of natural Father) The marriage with the natural father of my child has been dissolved through divorce and I remarried (Provide consent of natural Father or proof of full rights and responsibilities) As a widow I resumed my maiden surname / previous married surname The birth of my child out of wedlock has been registered under the surname of his / her natural mother / father and I wish for him / her to assume my surname (Provide consent of other Parent) I am the guardian of the minor (for the purpose of this section “guardian” includes any person who has in law or in fact custody or control of the child) I assumed my parent(s) surname and wish for my child(ren) to assume my surname Signature of father / mother / guardian Date signed Y Y Y Y M M M M M M M M M D D I , (full names and surname of father) _______________________________________________________________________________________________________________________________________________ Identity No./Passport No. and I , (full names and surname of mother) __________________________________________________________________________________________________________________________________________ Identity No./Passport No. We are the biological parents of (full names and present surname of the child): ___________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________________________________________________ Identity No./Passport No. born out of wedlock at (birthplace) ..................................................................................................................... on Y Y Y Y M M M M M M M M M D D We now apply for the alteration of the above-mentioned child’s surname in terms of section 25(2) of the Births and Deaths Registration Act, 1992 (Act No. 51 of 1992). ............................................................................ ............................................................................ Signature of Father Signature of Mother NB: This affidavit must be completed and affirmed to simultaneously by both of the parents. 1. I certify that before administering the oath/affirmation I asked the deponents the following questions and wrote their answers in their presence (Mark with X) (a) Do you know and understand the contents of this declaration? Answer: Father Yes No Mother Yes No Yes No (b) Do have any objection to taking the prescribed oath? Answer: Father Yes No Mother Signature of Parent A (c) Do you consider the prescribed oath to be binding on your conscience? Answer: Father Yes No Mother Yes No Signature of Parent B 2. I certify that the deponents have acknowledged that they know and understand the contents of this declaration which was sworn to affirmed before me and the deponents’ signatures/thumb prints/ marks were placed hereon in my presence. NB: Where thumbprints or marks are being taken it must be certified at all times. Departmental date stamp Commissioner of Oaths Designation Official’s full name and surname User ID Business address Page 5 of 10 This gazette is also available free online at www.gpwonline.co.za