Know all men by these presents, that I A.B. of having been admitted to the office of priest [or deacon, as the case may be] in the Church of England, and having resigned [here to be inserted description of late preferment, if any,] do hereby, in pursuance of the Clerical Disabilities Act 1870 declare that I relinquish all rights, privileges, advantages, and exemptions of the office as by law belonging to it. In witness whereof I have hereunto set my hand and seal this day of 18 .
(Signed) A.B. (L.S.)
Executed by A.B. in presence of
C.D. of
[address and description of witness.]