FORM B1.

AFFIDAVIT BY APPLICANT
IN THE MATTER OF

The Rectification of Certain Records of Civil Status

AND
IN THE MATTER OF THE

Civil Status Act No. 9 of 2010

Please note: Before completing this affidavit, see affidavit guidance notes on page 5.

I, (i) ..................................................................................................................... , make Oath and say as follows:

1. That I reside at (ii) ................................................................................................................. in the country of

(iii) ........................................................................ , I am (a/an) (iv) ........................................................................
and my postal address is (v) ...................................................................................................................... .

2. That the Register of Births/Baptisms/Marriages/Adoptions/Deaths/Burials for the district/parish

of (vi) ............................................... for the year (vii) ........................... at number (viii) ................. , page/
leaf (ix) ................. , (x) .............................................................. denomination, be rectified by:
........................................................................................................................................................................................
........................................................................................................................................................................................
........................................................................................................................................................................................
........................................................................................................................................................................................

3. That the Register of Births/Baptisms/Marriages/Adoptions/Deaths/Burials for the district/parish

of (vi) ............................................... for the year (vii) ........................... at number (viii) ................. , page/
leaf (ix) ................. , (x) .............................................................. denomination, be rectified by:
........................................................................................................................................................................................
........................................................................................................................................................................................
........................................................................................................................................................................................
........................................................................................................................................................................................

(Please Turn Over)

1

FORM B1.4
4. That the Register of Births/Baptisms/Marriages/Adoptions/Deaths/Burials for the district/parish
of (vi) ............................................... for the year (vii) ........................... at number (viii) ................. , page/
leaf (ix) ................. , (x) .............................................................. denomination, be rectified by:
........................................................................................................................................................................................
........................................................................................................................................................................................
........................................................................................................................................................................................
........................................................................................................................................................................................

5. That the Register of Births/Baptisms/Marriages/Adoptions/Deaths/Burials for the district/parish

of (vi) ............................................... for the year (vii) ........................... at number (viii) ................. , page/
leaf (ix) ................. , (x) .............................................................. denomination, be rectified by:
........................................................................................................................................................................................
........................................................................................................................................................................................
........................................................................................................................................................................................
........................................................................................................................................................................................

6. That the Register of Births/Baptisms/Marriages/Adoptions/Deaths/Burials for the district/parish

of (vi) ............................................... for the year (vii) ........................... at number (viii) ................. , page/
leaf (ix) ................. , (x) .............................................................. denomination, be rectified by:
........................................................................................................................................................................................
........................................................................................................................................................................................
........................................................................................................................................................................................
........................................................................................................................................................................................

7. That the Register of Births/Baptisms/Marriages/Adoptions/Deaths/Burials for the district/parish

of (vi) ............................................... for the year (vii) ........................... at number (viii) ................. , page/
leaf (ix) ................. , (x) .............................................................. denomination, be rectified by:
........................................................................................................................................................................................
........................................................................................................................................................................................
........................................................................................................................................................................................
........................................................................................................................................................................................

FORM B1.4
8. That the Register of Births/Baptisms/Marriages/Adoptions/Deaths/Burials for the district/parish
of (vi) ............................................... for the year (vii) ........................... at number (viii) ................. , page/
leaf (ix) ................. , (x) .............................................................. denomination, be rectified by:
........................................................................................................................................................................................
........................................................................................................................................................................................
........................................................................................................................................................................................
........................................................................................................................................................................................

9. That the Register of Births/Baptisms/Marriages/Adoptions/Deaths/Burials for the district/parish

of (vi) ............................................... for the year (vii) ........................... at number (viii) ................. , page/
leaf (ix) ................. , (x) .............................................................. denomination, be rectified by:
........................................................................................................................................................................................
........................................................................................................................................................................................
........................................................................................................................................................................................
........................................................................................................................................................................................

10. That the Register of Births/Baptisms/Marriages/Adoptions/Deaths/Burials for the district/

parish of (vi) ............................................... for the year (vii) ........................... at number (viii) ................. ,
page/leaf (ix) ................. , (x) .............................................................. denomination, be rectified by:
........................................................................................................................................................................................
........................................................................................................................................................................................
........................................................................................................................................................................................
........................................................................................................................................................................................

11. That the Register of Births/Baptisms/Marriages/Adoptions/Deaths/Burials for the district/

parish of (vi) ............................................... for the year (vii) ........................... at number (viii) ................. ,
page/leaf (ix) ................. , (x) .............................................................. denomination, be rectified by:
........................................................................................................................................................................................
........................................................................................................................................................................................
........................................................................................................................................................................................
........................................................................................................................................................................................

(Please Turn Over)

3

FORM B1.4
12. That the Register of Births/Baptisms/Marriages/Adoptions/Deaths/Burials for the district/
parish of (vi) ............................................... for the year (vii) ........................... at number (viii) ................. ,
page/leaf (ix) ................. , (x) .............................................................. denomination, be rectified by:
........................................................................................................................................................................................
........................................................................................................................................................................................
........................................................................................................................................................................................
........................................................................................................................................................................................

13. That the Register of Births/Baptisms/Marriages/Adoptions/Deaths/Burials for the district/

parish of (vi) ............................................... for the year (vii) ........................... at number (viii) ................. ,
page/leaf (ix) ................. , (x) .............................................................. denomination, be rectified by:
........................................................................................................................................................................................
........................................................................................................................................................................................
........................................................................................................................................................................................
........................................................................................................................................................................................

....................................................................................
Deponent

Sworn at ......................................................... this ............... day of ......................................................... , 2011

BEFORE ME:

....................................................................................
Notary Royal/Justice of the Peace

FORM B1.4

Affidavit Guidance Notes

This affidavit must be sworn before a Notary Royal or Justice of the Peace. Where two or more options
are separated by a (/), the option which applies is to be underlined.
Numbered fields are to be completed as follows:
(i)
(ii)
(iii)
(iv)
(v)
(vi)

Insert applicants full name.

Insert applicants address.
Insert country in which applicant lives.
Insert applicants occupation. If applicant is unemployed, simply write unemployed.
Insert applicants postal address.
For Birth/Adoption/Death Certificates - insert district in which record holders birth/adoption/
death was registered, as is recorded at top of certificate. For Baptism/Marriage/Burial
Certificates - insert parish in which record holder was baptised/married/buried, as is recorded
at top of certificate.
(vii) For Birth/Adoption/Death Certificates - insert year in which record holders birth/adoption/
death was registered, as appears in upper left-hand corner of certificate. For Baptism/Marriage/
Burial Certificates - insert year in which record holder was baptised/married/buried, as is
recorded at top of certificate.
(viii) For Birth/Adoption/Death Certificates - insert number in register at which record holders birth/
adoption/death is recorded, as appears in column marked No. of Register on certificate. For
Baptism/Marriage/Burial Certificates - insert number in register at which record holders
baptism/marriage/burial is recorded, as appears at top of certificate.
(ix) For Birth/Adoption/Death Certificates - insert page in register at which record holders birth/
adoption/death is recorded, as appears at top of certificate. For Baptism/Marriage/Burial
Certificates - insert leaf in register at which record holders baptism/marriage/burial is
recorded, as appears at top of certificate.
(x)
For Birth/Adoption/Death Certificates - leave this field blank. For Baptism/Marriage/Burial
Certificates - insert record holders religious denomination, as is recorded at top of certificate.