54   No. 41970 GOVERNMENT GAZETTE, 12 OCTOBER 2018 L0000000001 A4. DECLARATION/ACKNOWLEDGEMENT OF PATERNITY OF A CHILD BORN OUT OF WEDLOCK 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 Y Y Y Y M M M M M M M D D M M Date Y Y M D D Y Y M M M M M M M M M D D A5. DETAILS OF THE APPLICANT ID No./ Passport No./ PR/ Refugee/ Asylum Seeker No. if foreigner Date of birth M M M Thumbprint Surname Previous/Maiden surname Forenames in full Place of birth: Country of birth Residential address Street Town/Village Province Telephone no., incl. area code Cell phone no. Postal code Citizenship Permit no. E-mail address Relationship to the child Mother (Parent A) Father (Parent B) Legal guardian (attach proof) Social worker, provide case no. (Attach copy of Court order) Next of kin, please specify A6. DECLARATION BY APPLICANT Does one of the parents have a pending application for asylum in the Repulic? Yes No If Yes, status of application and attach copy asylum seeker permit (s22 ito Refugees Act) I, _______________________________________________, 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. Applicant Date Initials and surname Relationship to the child Mother (Parent A) Y Y Y Y M M M M M M M M M D D M M M D D Place Signature Father (Parent B) Next of kin Legal guardian Social worker Child (15 years or older) Date Initials and surname Y Y Y Y M M M M M M Place Signature A7. PARTICULARS OF A PERSON WHO WITNESSED THE BIRTH (for birth that occurred at a place other than a Health Institution) 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. if foreigner 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 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 2 of 9 This gazette is also available free online at www.gpwonline.co.za M M M M M M M D D