AFFIDAVIT FOR CHANGE IN NAME

By this deed, I, the undersigned ________________________________________ (new name) of etc. now lately called __________________________________________ (old name), doing __________________________________________ (given profession or avocation) and resident of ________________________________________________ _______________________________ 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 ______________________________________________ and so that I and my wife and children and remitter issue may hereafter be called, know and distinguished not by my former name/surname, but assumed name/surname of __________________________________________________.

2. That for the purpose of evidencing such my determination declare that I shall at all times hereafter in all records, deeds and writings and in all proceedings, dealings and transactions, private as well and upon all occasions whatsoever use and sign the name of ___________________________________________________ as my name/surname in place and in substitution for my former name/surname.

3. That I expressly authorize and request all persons in general, relative and friends in particular at all times hereafter to designate and address me, my wife, my children, remitter issue by such assumed name/surname of __________________________ accordingly.

4. In witness whereof I have hereunto subscribed my former and adopted name/ surname of _____________________________________________________ and ______________________________________ office my signature and seal, if any, this ___________ day of __________________ 19 .

Signed, sealed and delivered by the

above name __________________

formerly _____________________

(THIS DECLARATION TO BE NOTARIZED BY NOTARY PUBLIC)