STATUTORY DECLARATION

We, (a) Gume Beldan, Jason Gio and Apa Berldon of Eastern Highlands Province

do solemnly and sincerely declare that (b)

We are the legal dependents of late Mayo Jio who passed away on the 29th of January 2021
at Angau Memorial Hospital.

We hereby claimed that as stated as the legal beneficiaries for the deceased, we would like
to claim the remaining funds that has remain in her NCSL account # 630051.

And we make this solemn declaration by virtue of the Oaths, Affirmations and Statutory
Declarations Act 1962 conscientiously believing the statements contained therein to be true
in every particulars.

Declared at ………………………………. (c) ………………………………………….

……………………………………………

……………………………………………

Dated ……..… day of … ………………. 2022 Before me-

(d) …………………………………………..

(e)………………………………………………..
Commissioner of Oaths
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(a) Here insert name, address and occupation of person making the declaration.
(b) Here insert the matter declared to. Where the matter is long it should be set out in numbered paragraphs.
(c) Signature of person making the declaration.
(d) Signature of a person before whom the declaration is made.
(e) Here insert title of person before whom the declaration is made.

Note – Any person who willfully makes a false statement in a Statutory Declaration is guilty of an indictable offence, and
is liable to imprisonment, with or without hard labor, for four years.
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Printed by G. Dadi, Acting Government Printer.-176/10 000/-6.86.