Statutory Declaration of CHANGE OF NAME
BY
SALLY EXAMPLE SMITH
I, SALLY EXAMPLE SMITH (formerly KELLY JO JONES, of 46 High Street,
Newtown in the county of Eastshire) DO SOLEMNLY AND SINCERELY
DECLARE as follows:
1. I was formerly called KELLY JO JONES and am a citizen of the United
Kingdom.
2. I absolutely and entirely renounce relinquish and abandon the use of my
former name of KELLY JO JONES and assume adopt and determine to
take and use the names of SALLY EXAMPLE SMITH in substitution of my
former name.
3. I shall at all times hereof in all records deeds documents and other
writings and in all actions and proceedings as well as in all dealings and
transactions and on all occasions whatsoever use and subscribe the said
name of SALLY EXAMPLE SMITH in substitution for my former names of
KELLY JO JONES so relinquished as aforesaid to the intent that I may
hereafter be called or known or distinguished not by my former names of
KELLY JO JONES but by the name of SALLY EXAMPLE SMITH only.
4. I authorise and require all persons at all times to designate describe and
address me by the adopted name of SALLY EXAMPLE SMITH and I make
this solemn declaration conscientiously believing the same to be true and
by the provisions of the STATUTORY DECLARATIONS ACT of 1835.
Signed : OLD NAME
Signed : NEW NAME
DECLARED AT *…………… THIS DAY *………….. BEFORE ME *………………
(*details to be entered by authorised person)
