IN THE UNITED REPUBLIC OF TANZANIA

THE REGISTRATION OF DOCUMENTS ACT

[CAP 117 R.E 2002]

DEED POLL FOR CHANGE OF NAME

BY THIS DEED, I, …………………………… female, adult, and a resident of Kigamboni district,

Dar es Salaam DO HEREBY absolutely renounce and abandon the use of my former name
…………………………… which appears in ……………….. and in lieu thereof DO assume and
adopt the name of ……………………………. so that I may hereafter be called, known and
distinguished not by my former names of …………………………. but by my assumed name of
……………………………….

AND PURSUANCE to such change of name as aforesaid, I HEREBY DECLARE THAT, I

shall at all times hereafter in all records, deeds and instruments in writing and in all actions
and proceedings and in all dealings and transactions and upon all occasions whatsoever use
and sign the said name of ………………………………………. as my name in lieu of the said
………………………………… renounced as aforesaid AND, I HEREBY AUTHORISE and
request all persons to designate and address me in the name of ……………………………
only.

IN WITNESS WHEREOF I have hereunto subscribed to my name of …………………………….

on the day, year and in the manner hereinafter appearing:

SIGNED and DELIVERED at Dar es Salaam

by the said ……………………………….. who is
known to me personally/introduced to me by ……………………………………...
..………………………………...the latter being Deponent
personally known to me this 18th day of February
2022.

Before me:
Signature: ………………………………………
Name: Jesse Joseph Mwanisawa
Address: P. O. Box 11298, Dar es Salaam
Qualification: Advocate & Commissioner for Oaths