SAMPLE STATUTORY DECLARATION
NAME CHANGE/ CLEARANCE CERTIFICATE/
NEW WATER SERVICE CONNECTION/ DISCONNECTION BY REQUEST
REPUBLIC OF TRINIDAD AND TOBAGO
IN THE MATTER OF THE STATUTORY DECLARATIONS ACT
CHAPTER 7:04
I, Name of Declarant, Marital Status, of Address of Declarant, in the Republic of
Trinidad and Tobago, Occupation, do solemnly and sincerely declare as follows:-
1. That the facts deposed to herein are true and accurate and within my personal
knowledge and belief, save where stated to be on information in which case I verily
believe same to be true and correct.
2. That I, Name of Declarant am the declarant herein and the holder of Identification
Number.
3. That the purpose of this Statutory Declaration relates to an Application to the Water
and Sewerage Authority for a [Change of Name on Account/ Clearance Certificate/
New Water Service Connection/ Disconnection by Request] (hereinafter referred to
as “the said Application”)
4. That I am the owner/occupant of Address of Property (hereinafter referred to as “the
said property”) relative to Account No.1 with respect to the said Application.
5. I agree to pay all costs incurred by the Water and Sewerage Authority relative to the
said Application (whether voluntary or otherwise).
6. I accept that the provision of services by the Water and Sewerage Authority under the
said Application does not represent that the Water and Sewerage Authority
acknowledges that I have any right, title or interest in the said property.
7. This Statutory Declaration is not intended to be nor should it be deemed or construed
to be an admission or concession of my ownership of or my right, title or interest in
the said property by the Water and Sewerage Authority.
8. I also hereby acknowledge that failure to pay rates within three (3) months of same
becoming due or failure to adhere to the provisions of the Water and Sewerage Act
Chapter 54:40 may result in disconnection without further notice and any further
action by the Authority pursuant to the provisions of the Water and Sewerage Act
Chapter 54:40 and the Rates and Charges Recovery Act Chapter 74:03.2
9. I agree to notify the Authority (in writing) immediately upon my ceasing to occupy
the said property and to pay all outstanding water and sewerage rates in respect of the
said property. Further, I agree to pay all water and sewerage rates billed for the period
prior to my written notification of change in occupation to the Authority.
10. I hereby release, discharge and indemnify the Water and Sewerage Authority, its co-
licensees and its respective servants, agents, representatives, contractors and its
successors-in-title from and against any and all claims including but not limited to,
causes of action, proceedings, rights, actions, demands, damages, expenses, losses
and liabilities of any nature whatsoever whether now apparent or known to me in
respect any name change and/or water and/or sewerage connection made and/or
disconnection to the said property and/or clearance certificate issued, on reliance of
the information detailed and/or set out in this declaration.
1
Reference to the Account No. may be disregarded where the Application relates to a New Service
Connection or a Clearance Certificate (if no Account exists).
2 This Clause is applicable relative to an Application for a New Service Connection.
SAMPLE STATUTORY DECLARATION
NAME CHANGE/ CLEARANCE CERTIFICATE/
NEW WATER SERVICE CONNECTION/ DISCONNECTION BY REQUEST
AND I make this declaration conscientiously believing the same to be true and according
to the Statutory Declarations Act Chapter 7:04 of the Laws of the Republic of Trinidad
and Tobago, and I am aware that if there is any statement in this declaration which is
false in fact which I know or believe to be false as and do not believe to be true I am
liable to fine and imprisonment.
DECLARED to by }
at }
}
this the day of , 2018. }
Before me,
Commissioner of Affidavits
