Forms 1, 1-A, 1-B

This is to certify that ___________ [name of the communicant member]________ is a member of the _________ [name and location of the congregation] _______, and is at his/her own request, hereby dismissed to unite with the ________ [name and location of the congregation]________________.

(The first paragraph may be amended to include other communicant members from the same family transferring to the same congregation. If there are baptized children, not communicant members, it should be noted here, and their name(s) should be recorded.)

Given this _______________ day of ____________________ in the year _____________, by order of the Session.

_____________________________ ______________________________ Clerk of the Session Moderator of the Session

This certificate is valid for one year from the date of issue for transfer within the denomination. For transfer from the denomination the transfer becomes effective immediately.

If the issuing Session desires to state exceptions, or grounds of censure in the certificate, they should be noted above the signatures of the Clerk and Moderator. This certificate should be given to the communicant member(s).