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Evidence of Life
In the _______________ Division of the High Court
Evidence of Life
Declaration of person
entitled to payment
A/c No.
Full Account
Title
To the Accountant General, Court Funds Office, 22 Kingsway, London WC2B 6LE
I _____________________________________________________________________________________
of ____________________________________________________________________________________
_______________________________________________________________________________________
Fo
declare that I was living on _______________________ 19 ___
Either
Insert full
names of,
e.g. patent,
minor or
minors
and that
Cross out
words not
applicable
alive
was/were then
or
and I was then
Complete, if
applicable,
by inserting
Minister or
Treasurer etc.
of
Signed
Address ________________________________________________________