CERTIFICATE FOR COMMON LAW RELATIONSHIP

INSTRUCTIONS – A Justice of the Peace, Notary Public, Priest or Minister of Religion,

Medical Doctor or Attorney-at-Law must complete this certificate.

I ___________________________________________________________________________________________________________________________________________________________ of
_______________________________________________________________________________________________________________________________________________________________
Address

CERTIFY that:-

1. ____________________________________________________________________ an employee of _______________________________________________________________

Name of Employee Name of Employer

has been known to me personally since the year _______________ and that __________________________________________________________
Name of Spouse

of ___________________________________________________________________________________________________ has also been known to me personally

Residence of Spouse

since the year ______________________ .

2. From my personal knowledge I can state that the said_____________________________________________________________________________

and _______________________________________________________________________ have been cohabiting continuously as spouses since the

month of ____________________________________ .

Certified this________________________________ day of _____________________________________________________.

____________________________________________________________________
Signature

____________________________________________________________________
Name (Please Print)

____________________________________________________________________
Title (Please Print)

GI40016
 DECLARATION FOR COMMON LAW RELATIONSHIP

I ______________________________________________________________________________________________________________________________________________________________

of ____________________________________________________________________________________________________________________________________________________________

Declare as follows:-

1. I am an employee of _________________________________________________________________

2. I have been cohabiting continuously with ____________________________________________________________________________________________

as my spouse since the month of _______________________________________________ .

3. I have registered the said ____________________________________________________________________________________________________________________

of ______________________________________________________________________________________________________________________________________________________
Residence of Spouse

as my spouse with my employer.

DECLARED at )

This day of )

Before me:

________________________________________________________________
Justice of the Peace