83 Insurance Brokers cc ‘An Authorized Financial Serve Provider FSP Number. 20882 |Asepeate form mustbe completed foreach 1 Main Reet Road, Benoni, 1501 poly thatreques amendments, 0 Box 3597, Benoni, 1500 Tok (O11) 747-540001 Fax: (011) 422-2448 AFFIDAVIT CUSTOMARY MARRIAGE 33 Stee ee For Service Beyond UUbuntu ee POLICYHOLDER INFORMATION i Tile ine | SS Fasten’ THEM A SISSY - 2 y rane PHILA Dinter [FIFO 6 ISIBIOGISIFMORO mM CLI LL “ekephoe one) LI [| wer| || i number CI L_| [emai ception “compulsary elds DECLARATIONS |) I Identity number customarily married t. Cees ae I know and understand the contents of the above-mentioned statement. Ihave no objection to take the prescribed oath and consider the prescribed oath to be binding on my conscience. Signed before a Commissioner of Oaths at ON This anne day Of 2 Signatui Signed and sworn before me on this. COMMISSIONER OF OATHS OFFICIAL STAMP