(To be typed on Rs.
50/- Non Judicial Stamp Paper and Notarized copy to be presented)
AFFIDAVIT
I, ____________________________________________________________ son / daughter
of _______________________________, ______________ yrs of age, married / unmarried,
resident of __________________________________________, Indian National, do hereby
solemnly affirm and declare on oath as under –
I say that my Birth is registered at office of Sub Registrar of Birth at ______________
within the jurisdiction of _______________ Taluka under Registration No. _______________
dated: ________ and my date of Birth is ______________.
I say that on my Birth Certificate my name is recorded as
____________________________________________________________________________.
I say that I am popularly known in the locality by name ____________________________
__________________________.
I say that the names “_________________________________” and
“______________________________” are of the one and the same person i.e. myself.
I say that I want to change my name from ______________________________________
to____________________________________________ as per Section (2) of Section 3 of the Goa
Change of Name and Surname Act, 1990.
I say that I am swearing this affidavit in order to produce the same at the office of the Civil
Registrar-cum-Sub Registrar at __________________ in order to enable me to change my name.
I say that the contents of the above paras of my affidavit are true to the best of my
knowledge and belief and that I have not misrepresented any facts.
Solemnly affirmed before me at _________________, Goa on this ______ day of the month
of ________________________ of the Year _______________
Deponent
Identified by:
