No. 41970   81 STAATSKOERANT, 12 OKTOBER 2018 C. DECLARATION / OATH / AFFIRMATION NOTE: Commissioner of Oaths must be an authorised DHA official at the office where application is submitted I,_____________________________________________________________(parent(s) / next of kin / legal guardian), hereby declare under oath that the information submitted in this Affidavit and the Application for Birth, Marriage or Death certificate, confirmation of birth and marriage or death register is true and correct, and I understand that a false statement is punishable by law. Signature of deponent: Date signed: Y Y Y Y M M D D I certify that before administering the oath I asked the deponent the following questions and wrote down his/her answers in his/her presence: (1) Do you know and understand the contents of this declaration? Answer: (2) Do you have any objection to taking the prescribed oath? Answer: (3) Do you consider the prescribed oath to be binding on your conscience? Answer: I certify that the deponent has acknowledged that he/she knows and understands the contents of this declaration which was sworn to/affirmed before me and that the deponent’s signature or mark was affixed to the declaration in my presence. Signature of Commissioner of Oaths Full first names and surname Designation (rank) Business Address Date Place The deponent and the Commissioner of Oaths to initial each page of the Affidavit. Office stamp - OFFICE OF ORIGIN D. FOR OFFICIAL USE ONLY APPLICATION RECEIVED BY: DOCUMENTS SUBMITTED: PLEASE TICK Surname Copy of Identity Document of applicant Forenames in full Proof of legal guardianship Persal No. Power of Attorney Date Y Y Y Y M M D D Payment received, if applicable Copy of Passport, incl. visa/permit Signature Office stamp - OFFICE OF ORIGIN FOR OFFICE USE ONLY DHA-154/132/130 APPLICATION FOR A COPY OF A CERTIFICATE DHA-25 A0000000001 Identity Number / Asylum / PR number of a person whose certificate is required OFFICE DATE STAMP User ID Signature This gazette is also available free at www.gpwonline.co.za Page 2 online of 2