Deed poll
STATUTORY DECLARATION FOR AN ADULT
LOC021
06.15
This form must be completed by a person who has known the applicant (the person changing their name) for 10 years or
more, is not related to the applicant or their partner; is a Commonwealth or British citizen and is a home owner - See page 2
of guidance notes.
Declarant’s
name
Declarant’s home address
Occupation
I do solemnly and sincerely declare as follows:
I AM
British Citizen British Dependent Territories Citizen
Commonwealth Citizen
Under section of the British Nationality Act 1981
and a Home Owner residing at
(DECLARANT’S HOME ADDRESS)
I HAVE for years and upwards known
(APPLICANT’S NEW NAME)
formerly known as
(APPLICANT’S OLD NAME)
who has executed the Deed now produced and shown to me marked “A” and whom I identify as
the person referred to in the documents exhibited to this Declaration.
The certificate of
(NAME THE DOCUMENT SHOWN AS PROOF OF CITIZENSHIP)
now produced and shown to me and marked “B” is the Certificate of
(NAME THE DOCUMENT OF CITIZENSHIP)
Note: Please make sure
that you enter the name
of the same document in
both boxes
continued over the page
of the said
(APPLICANT’S NEW NAME)
formerly known as
(APPLICANT’S OLD NAME)
I declare from my personal knowledge of the said applicant’s and of their change of name and I
make this solemn Declaration conscientiously believing the same to be true and by virtue of the
provisions of the Statutory Declaration Act 1835.
What to do next Once you (the declarate) has completed this form you must take it to a solicitor, commissioner for
oaths or an officer of the Senior Court for you to swear that the information given is true.
You will be charged a fee to do this.
DECLARED by the above named
(DECLARANT’S NAME)
at
(ADDRESS WHERE DECLARATION TOOK PLACE)
Dated
D D
/
M M
/
Y Y Y Y
Before me
Solicitor Commissioner for Oaths Officer of the Senior Court
LOC021 (06.15)
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