IPlNlllKENffII Page 98 (Subsidiary) Form TM ]6 DECLARATION (ONLY TO BE FURNISHED \VHEN REQUESTED BY THE REGISTRAR) IN SUPPORT OF STATEMENT OF CASE ACCOMPANYING" FORM Ttv1 14 OR T~l·15 I, , of . do solmenly and sincerely declare as follows: . The particulars set out in the Statement of Case, exhibit marked ................ and left by me in connex ion with my request to be registered as subsequent proprietor of the Trade Mark No in Class . , are true and comprise every material fact and document affecting the present proprietorship of the Trade Mark. I make this -declaration conscientiously believing fhe same to be true and according to the Oaths and Statutory Declarations Act. Declared at (a) To be signed by the person making the de­ claration. } ................... (a) day of this , 19 . Before me, Signature and title of authority before whom declara­ tion is made. (b) ..................................•..... (b) To: The Registrar of Trade Marks, P.O. Box 30031, Nairobi. 52 of 86