Land Titles

FORM AAffidavit Regarding A Name Change

I, of

make oath and say that:

a. I am the registered owner of the following land:

(LINC number: ) - OR - I am the owner of an interest pursuant to the following instruments or caveats:

b. I was married on at

to and I have now adopted the

surname . - OR -

I entered into an Adult Interdependent Relationship on and have

now adopted the surname .

c. I had previously adopted the surname

which is the name of my spouse or adult interdependent partner (or former spouse or former adult

interdependent partner) but I now use the surname which is:

I have attached an official record of my birth, marriage, divorce, adult interdependent agreement (if applicable), affidavit by my adult interdependent partner confirming surname or any other evidence required by the Registrar to substantiate identity.

SWORN before me at

in the

this day of ,

(A Commissioner, Etc. (or as the case may be)) (Signature of Person Signing) (Print Name of Commissioner) (Expiry Date of Commission)

This information is being collected for the purpose of land titles records in accordance with the Land Titles Act. Questions about the collection of this information can be directed to the Freedom Of Information and Protection Of Privacy Co-ordinator for Alberta Registries, Research and Programme Support, Box 3140, Edmonton, Alberta T5J 2G7, (780) 427-2742.