APPLICATION

TO NOTE CHANGE OF NAME

(of a natural person)

Fo rm A4

C E R TIFI C A TE (S ) O F TI T LE A F FE C TE D

Volume <<Sell|Enquiry Information|FromExisting|Volume>> Folio <<Sell|Enquiry

Information|FromExisting|Folio>>

E S TA T E A N D I N TE R E S T

<<Sell|Enquiry Information|FromExisting|EstateInterest>>

A P P LI C A N T

<<Sell|Name Changes|newName>>
I .......................................................................................................................................................................................
<<Sell|Client|Physical Address>>
of .....................................................................................................................................................................................
do s olemnly and si nc er ely decl ar e that I am r egis ter ed in the name

<<Sell|Name Changes|oldName>>
of .....................................................................................................................................................................................
as * the / one of the pr oprietor(s) of the l and abov e desc ribed
and that I * ha v e c ha nge d m y na m e / a m r e gi s te r e d i nc or r e c tl y as a c ons equenc e

<<Sell|Name Changes|changeReason>>
of .....................................................................................................................................................................................
and I apply to hav e my name * c ha n ge d / c or r e c te d on the Cer tific ate(s) of Ti tle abov e descri bed and I mak e this sol emn
decl ar ation c ons cienti ously beli evi ng the s ame to be tr ue and by virtue of the O aths Ac t 1936.

DA TE D ......................................................................

Decl ar ed and s ubsc ri bed at ................................................

by the s ai d .........................................................................
who is eit her pers onall y k nown to me or has s atis fi ed

............................................................
(S ig n atu re of D e c la ra nt )

me as t o his or her i denti ty this .............. day

of............................................. 20 ..........
befor e me.
...................................................................
(S ig n at u re of A ut h o ris e d F u n ct io n a ry )

...........................................................................................
P rint F u ll N a m e of A u th o ris e d F u n ct io n a ry

...........................................................................................
A d d re ss of A uth o ris e d F u n ct io n a ry

...........................................................................................
B u s in es s H o u rs T e le p h o n e N u m b e r ...................................................

* Delet e t he in applicable

G uidan ce Note s a vailable

LAN DS TITLES REGISTRATION

OFFICE
S O UT H A U ST R A LIA

APPLICATION TO NOTE
CHANGE OF NAME
F OR M A P P R O V E D B Y T H E R E G IST R A R-G E N E R A L
Prefix

B E L O W T H IS L I N E F O R O F F I C E &
ST A M P D UT Y P U R P O S E S O NL Y

CN
Series No.

B E L O W T H IS L I N E F O R A G E N T U S E O N L Y
C ER TIFI E D C O R R E CT F O R TH E P U R P O S E S
O F T H E R E A L P R O P E R T Y AC T 18 8 6

S olicit o r/R e gist e red C o nv ey a nc e r/ A pp lic a nt

A G E NT C O D E

Lodged by:

Correction to :

TIT L E S, C R O W N L E A S E S, D EC L A R ATI O N S E TC. L O D G E D W ITH

IN ST RU M E NT (T O B E FI L L ED IN B Y P E R S O N L O D GI N G )
1. ...............................................................................................................
2. ...............................................................................................................
3. ...............................................................................................................
4 ................................................................................................................

P L E A S E I S S U E N E W C E RTIFI C AT E (S ) OF TIT L E A S F O L L O W S
1. ...............................................................................................................
2. ...............................................................................................................
3 ................................................................................................................
4 ................................................................................................................

D E L IV E R Y IN S T R U C T I ON S (A g e nt to c om p let e )
P L E A S E D E LI V ER TH E F O L L O WIN G IT E M(S ) T O T H E
UN D E RM E N TI ON E D A G E NT (S )

ITEM(S )

CO RRE CT IO N

PAS SE D

AGENT CODE

RE G IS TE RE D

RE G IS T RA R- GE NE RA L
R- G 25050 5