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= v a -BEeDIGDE VERKLARRING STATEMENT UNDEROATH THado: Samaeians Ld eo we. 121239 ORO 5B J Gender: Fanaia I tangusge: Zly Resiuinga, D> C1REAT RRHain Employed es: mMestte [eee ee A ere EE Tel. No (4),_O Tel. No (We, cet No. O182072 418 sv ‘STATE UNDER OATH | SOLEMNLY DECLARE IN ENGLISH: Dam te mote fot Lees gels Ne ore ig ohll (a peimany . aad Tew works I at Wore Taw = 7 a h me wt! the™poog a m4 cl cg. Raid Fw ein: 3S$o~00 also help! ce “tknow ond understand the content ofthis statement “Unvave / have no objection to taking the prescribed oath | ‘Tensider donot consider the oath tobe binding on my ecisclonce Meenas; {cert thet the above statoment was taken by the me, and thatthe depénent has acknowledged that HefShe knows and understan ontents ofthis statement. This statement wes sworn io /afrmed before me and ie depanent’s Signature / mark / thumbprint was placed before my presence. we IELOS.

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