I. . . . . . . . . . . . . . . . . . . do hereby declare that to the best of my knowledge and belief what is
stated above is correct complete and is truly stated.
Verified today the . . . . . . . . . . . . . . . . . . . day of. . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . .
Signature of the person providing the information
Place: . . . . . . . . . . . . . . . . . . .
Notes :
1. *Delete whichever is not applicable.
2. #Write N.A. if the relevant information forms part of the certificate referred to in sub-section
(4) of section 90 or sub-section (4) of section 90A.