DECLARATION OF SUBSISTING MARRIAGES

AND / OR COHABITATION RELATIONSHIPS

I,

Of (address):

Declare as follows:

1 The deceased

was well known to me since

2 Mark the applicable box with an X below:

I know that the deceased was a partner in one/more Customary Union(s) at the time of his/her death.

I know that the deceased was a partner in one/more Religious Marriage(s) at the time of his/her death.

I know that the deceased was a partner in a same-sex cohabitation relationship at the time of his/her death.

I know that the deceased entered into a civil marriage and was still a partner thereto at time of his/her death.

I know that the deceased was unmarried/widowed/divorced at the time of his/her death and was not a partner to any
customary or religious marriage, nor was he/she a partner in a same-sex cohabitation relationship at the time of
his/her death.

3 Full particulars of all partners as mentioned above:

(Please indicate full names, ID number and contact details, if available)

Full Name ID Number Contact Details

4 Signature of Deponent

Signed and sworn to/affirmed before me at ____________________________ this __________ day

of _________________ in the year _____

__________________________________
Signature of Commissioner of Oaths