Form 5001a - Fsm Passport Application Form Page 4

AFFIDAVIT

FOR LOST/DAMAGED OR STOLEN FSM PASSPORT

Application for Renewal or Replacment of FSM Passport

I, _____________________________, citizen of the Federated States of Micronesia

(Full legal name as shown on passport)

(FSM), born in __________________ State in the FSM on ____________________,

(Place of Birth)

(Date of Birth)

hereby verify and confirm that I am applying for a renewal or replacement FSM passport

because my previous FSM passport was:

( )

damaged and hereby attached to this application

( )

stolen

( )

lost

I swear that this statement is true and hereby submit my application for a new FSM

passport.

Signature________________________________

Date

________________________________

* This affidavit must be notarized.

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Parent category: Life