Government of Belize

Registrar General Department

VITAL STATISTICS UNIT

STATUTORY DECLARATION FOR THE CORRECTION OF ERROR OF FACT

In the matter of an Error in the Register of the Marriage certificate of _ IGNACIA

Christian (first)

_BERTHITA ___ POT ___ registered on the 8th _

Middle Surname Day

_JULY _, __1995 , in Entry # 820 of 1995 in the Register Book

Month Year

In the District of , ________Cayo District__________

I JUAN ____ MIGUEL ___ _ TZIB _, ( HUSBAND )

Christian (First) Name middle Surname

Of __ _ _ _ _ San Antonio ___ ___Cayo______

Street Address Village District

Do solemnly and sincerely declare that (here set forth nature of error to be corrected and the
true facts of the case)

FOR THE NAME “ IGNACIA BERTHITA POTT” TO READ “ IGNACIA BERTHITA

POT”
And I make this solemn Declaration conscientiously believing the same to be true, and by
virtue of the provisions of chapter 157 of the Laws of Belize R.E. 2000

________ _______
Declarant’s signature

JUAN MIGUEL TZIB _______

Declarant’s Name

Before me, the undersigned ______________________________________, justice of the peace

For the District of ______________________ this __________day of ______________________

In the year of Our Lord, Two Thousand and ______________________________

_____________________________________
Signature of Justice of the Peace