To the competent authorities
born in the year —
place of residence — (passport – -, issued on —- by department of the Ministry of Internal Affairs of Ukraine in – –)
identification # —
I, citizen of Ukraine, —, being in my right mind, clear memory, acting voluntary and understanding meaning of my actions without any physical or moral constraint, hereby certify that I am not officially or virtually married, and I was not officially or virtually married neither on the territory of Ukraine nor outside Ukraine.
I have completely read the text of this statement. The content of the statement is clear to me and corresponds to my will.
SIGNATURE: Signature —-.
—-, town of —, —, Ukraine
I, —, private notary of the — municipal notarial district in —- oblast, certify the authenticity of the signature of the citizen —. (place of residence —-) who personally came to me and is known to me as a person, stated in this document, signed the document in my presence and properly confirmed the drawing up of this document.
Registry # —-
Payment received in accordance with the asset 31 of the Law of Ukraine “About Notary activities”
Private notary: Signature —
Round official seal
— # —
Attention! This blank has a multilevel falsification protection.
Ministry of Justice of Ukraine