Effective date of the change of name and/or address:_________________________________________

Current name under which you are authorized to act as a Dedimus Justice:

__________________________________________________________________

New name under which you will be authorized to act as a Dedimus Justice:

__________________________________________________________________

Signature: __________________________________________________

Current home mailing and physical address
(please provide complete address for both including zip code):

__________________________________________________________________

__________________________________________________________________
^{(mailing address)}

__________________________________________________________________

___________________________________________________________________
^{(physical address, if different from above)}

E-mail address:______________________ Other language fluency:_________________

Current town/city of residence:________________________ Date of Birth:____________

Telephone numbers: Home:______________________Work:_______________________

IF YOU WISH TO RECEIVE A NEW DEDIMUS JUSTICE CERTIFICATE OF OFFICE SHOWING THE ABOVE CHANGE, PLEASE INCLUDE A COPY OF YOUR CERTIFICATE WITH THIS FORM. If you are filing a change of name, please include a photocopy of the paperwork authorizing the change, such as a marriage certificate or divorce decree.

Dedimus-1 Rev. D10/2002