_____________________ do hereby solemnly declare:
1.

That for and on behalf of myself and my wife and children and remitter issue wholly renounce/relinquish and abandon the
use of my former name/surname of (given name)(surname)___________________________________________________
and in place thereof I do hereby assume from this date the name/surname _________________________________________
and so that I and my wife and my children and remitter issue may hereafter be called, known and distinguished not by my
______________________________________________________________________________________________________
2.

That for the purpose of evidencing such my determination declare that I shall at all times hereafter in all records, deed and
writings and in all proceedings dealings and transactions, private as well and upon all occasions whatsoever use and sign the
name of(given name)(surname)___________________________________________________________________________
________________________________________________________________________________________________as my
3.

That I expressly authorize and request all persons in general, relative and friends in particular at all times hereafter to
designate me, my wife, my children, remitter issue by such assumed name/surname of (given name)(surname)___________
__________________________________________________________________________________________ accordingly.
4.

In witness whereof I have hereunto subscribed my former and adopted name/surname of(given name) __________________
and(surname)__________________________________________________________________________________________

Signed, sealed, and delivered by the above name(given name)(surname) __________________________________
formerly _______________________________________________________________________ in the presence of
1.

Name _________________________________________________________________________________
Address _______________________________________________________________________________
2.

Name _________________________________________________________________________________
Address _______________________________________________________________________________


(This deed poll/affidavit may be signed and attested in presence of a Notary Public)
(given profession or avocation) and resident of
etc. now lately called__________________________________________________________________________(old name),doing
________________________________
_____________________________________________________________________________________________
office my signature and seal, if any, this ______________________day of_____________________________
____________________________________________________________________________________________________
_____________________________________________________________________________(given name)(surname)(new name)
name/surname in place and substitution for my former name/surname.
former name/surname,but assumed name/surname.