Fillable Renunciation Declaration Form printable pdf download

Renunciation Declaration Form

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Include an Affidavit

of Loss with this

Renunciation

Declaration

RENUNCIATION DECLARATION

1. I _____________________________________________________ (here insert name and

John Smith, 123 Your Street, San Francisco, CA

address of declarant) am of full age and capacity and was born at (with Tehsil, District, State

and Country) ______________________ on __________________.

New Delhi, India

1/JAN/1980

2. I have/have not been married.

Yes

3. I have acquired US/Foreign nationality on _______________ and consequently have obtained

2/FEB/2000

US/Foreign passport no. : ______________ dated ________________.

123456789

3/MAR/2010

Example: Name,

4. I hereby declare that my Indian Passport is “Lost/Misplaced”.

Date and Place of

5. Father’s Name: ______________________

Birth, Current

Bob Smith

Nationality,

6. Applicant's Date of Birth: ___________________________

1/JAN/1980

Passport Number

7. Names and full particulars of my minor children, if any, who are/were Citizens of India

____________________________________________________________________________

Jim Smith, Born 4/APR/1999 in New Delhi, INDIA, Nationality: U.S., Passport # 987654321

I, ____________________________________________ do solemnly and sincerely declare that

John Smith

the foregoing particulars stated in this declaration are true and I make this solemn declaration

conscientiously believing the same to be true.

Made and subscribed this __________ day of __________________

1st

July, 2014

Phone No:

Name:

555 123-4567

John Smith

E-mail:

Signature:

US Address:

123 Your Street, San Francisco

Do not Fill Out the Section Below -

RENUNCIATION DECLARATION

Consulate Officer Will Fill This Out

Date: ____________

This is to certify that Mr./Ms. __________________________________ has renounced his/her

Indian citizenship and acquired ___________________ (name of the country) Citizenship.

His/Her original Indian Passport is “not surrendered and claimed as lost/misplaced”.

Signature & stamp (Consulate Officer)

Renunciation Declaration Form

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