Form 6 Declaration Of Lost, Stolen Or Mutilated Belize Passport (Page 2 of 2) in pdf

Form 6 Declaration Of Lost, Stolen Or Mutilated Belize Passport Page 2

POLICE REPORT

HAS THE LOST/ THEFT OF THE PASSPORT BEEN REPORTED TO THE POLICE?

YES [ ]

[ ]

DATE REPORTED TO POLICE

___/__

___/___/___/___

Day

Month

Year

POLICE STATION/___/___/__/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/

AND ADDRESS

_/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/__/

DETAIL HOW, WHEN OR WHERE THE LOSS, THEFT OR MULTILATION OF THE PASSPORT OCCURRED.

______________________________________________________________________________

_____________________________________________________.

HAVE YOU HAD ANY OTHER BELIZE PASSPORT LOST, STOLEN OR MUTILATED? (Yes ( ) NO( )

STATE THE COUNTRIES FOR WHICH YOU HAD VISAS ENDORSED IN THE PASSPORT

I the undersigned certify that the information provided herein is correct and that I have not sold, pledge or otherwise given my passport to

another person or disposed of it in an unauthorized manner. I understand that upon submission of this form, the related passport would be

invalidated and can no longer be used. If the passport is subsequently found or recovered. I will immediately return same to the nearest

Passport Office or Belize Foreign Mission

Dated

___/__

___/___/___/__

…………………………………………

Day

Month

Year

Signature of Applicant

CERTIFICATION BY THE COMMISSIONER OF AFFIDAVITS, JUSTICE OF THE PEACE OR NOTARY PUBLIC

Made and subscribed this _________________day of _________________________ in the year ___________________________

before me

…………………………………………………….

………………………………………………………

Name in Block Letters

Signature

…………………………………………………..

Official Title

Form 6 Declaration Of Lost, Stolen Or Mutilated Belize Passport Page 2