I, the undersigned First Name Last Name(date of birth Date ) give authority to First Name Last Name to Please Select divorce my wife divorce me from my husband First Name Last Name (date of birth Date ), a Please Select Talaq Raj’i Talaq Khul’i in accordance with Islamic law.
I confirm that MRS Consultants have offered us mediation in an effort to achieve reconciliation.
First Name Last Name
Signature
Date