By this deed I, the undersigned________ previously called ________, doing________ and resident of________ solemnly declare:-
1. That for and on behalf of ________and remitter issue wholly renounce/relinquish and abandon the use of my former name/surname of ________ and in place thereof I do hereby assume from this date the name/surname ________ and so that I and my ________ and remitter issue may hereafter be called, known and distinguished not by my former name/surname, but assumed name/surname of ________
2. That for the purpose of evidencing such my determination declare that I shall at all times hereafter in all records, deeds and writings and in all proceedings, dealings and transactions, private as well as upon all occasions whatsoever use and sign the name of________as my name/surname in place and in substitution of my former name/surname.
3. That I expressly authorize and request all persons in general and relatives and friends in particular, at all times hereafter to designate and address me,________, remitter issue by such assumed name/surname of ________accordingly.
4. In witness whereof I have hereunto subscribed my former and adopted name/surname of ________ and ________affix my signature and seal, if any, this ________ day of ________
Signed sealed and delivered by the above name