I, , do hereby give formal notice of my defection from the Roman Catholic Church. I want it to be known that I no longer wish to be regarded as a member of the Roman Catholic Church.
I further declare that I am aware of the consequences of this act regarding the reception of the sacraments of the Church, including the sacraments of the Eucharist, marriage and the sick and also with regard to burial.
I undertake to make this decision known to my next of kin and to ensure that they are aware of these circumstances in the case of my being incapacitated.
I acknowledge that I make this declaration under solemn oath, being of sound mind and body, and in the presence of a witness who can testify as to the validity of this document.