[PROVISIONAL TRANSLATION FROM PERSIAN]

[Translator’s notes appear in square brackets]

[Personal information has been redacted.]

In the Name of God

The Personal Status Registration Office is obligated to investigate the religion [illegible] of those who believe in the Baha’i sect, in accordance with Verdict number [illegible] (5/12/1359) [24 February 1981]; therefore, please answer the following questions:

[signature]

Please introduce yourself: Ezzatollah Ahmadian

What is your religion? In accordance with Article 23 of the Constitution, it is prohibited to require an individual to identify his belief.

3- Please clarify in case your religion is other than Islam or one of the officially recognized religions of the Islamic Republic: I believe in all divine religions

Ezzatollah Ahmadian

[Signature]

9/1/1360 [29 March 1981]

4- Please state in writing if you believe in the religion of Islam, otherwise are you willing to convert to Islam? I do believe in God, the prophet hood of Moses, Jesus, and Mohammad the Messenger of God.

Ezzatollah Ahmadian

[Signature]

9/1/1360 [29 March 1981]