Date:
To whom it may Concern.
Dear Sir/Madam,
I the undersigned, having sole parental responsibility for (insert
child's or children's current full name or Names here)
consent to (His/Her Name or Names) being changed to (Insert new full name
or Names here).
If you live in
England or Wales this paragraph will need to be added,
if for births
registered before 1 December 2003
I confirm that I was not married to my (child's or children's) father
at birth and no other person has acquired parental responsibility by
agreement or by court order.
If
you live in England or Wales this paragraph will need to be added,
if for
births registered on or after 1 December 2003
I confirm that I was not married to my (child's or children's)
father at birth and no other person has acquired parental
responsibility by agreement or by court order. I also confirm that the
father is not recorded on my (child's or children's) birth certificate.
If you live in Scotland this paragraph will need to be added.
I confirm that I was not married to my (child's or children's)
father at the time of conception and no other person
has acquired parental responsibility by agreement or by court order.