Form 206

Evidence of Life
Evidence of Life Declaration In the _______________ Division of the High Court
of person entitled to ____________________________ District Registry
payment
Please use BLOCK CAPITALS A/c No.
Full Account
Title

To the Accountant General, Court Funds Office, 22 Kingsway, London WC2B 6LE
I _____________________________________________________________________________________

of ____________________________________________________________________________________
_______________________________________________________________________________________
Fo
declare that I was living on _______________________ 19 ___
(Tick and complete if appropriate)
Either
Insert full
names of, and that
e.g. patent,
minor or
minors
named in the Order dated _______________________ 19 was/were then
Cross out
words not alive and was/were under the age of 18 years/a patient.
applicable or
and I was then
Complete, if
of
applicable,
by inserting
Minister or
Treasurer etc.
Signed
(Signature of person entitled to payment)
 This declaration should be witnessed by
a person who knows the declarant Declared before me on the _________________________________19 ___
personally and who is a Member of
Parliament, Minister of Religion, Doctor,
Signed
Lawyer, Bank Manager or a person of (Signature of witness)
similar standing.
Address ________________________________________________________

 This declaration should not be witnessed

by a relative of the declarant.
Qualification ______________________________________________________

Court Funds Rule 40.