A
C
C
FFIDAVIT
ONCERNING
IRCUMSTANCES
R
L
P
EGARDING THE
OSS OF
ASSPORT
(P
P
)
LEASE
RINT
I,
residing at
(F
N
,
M
N
,
L
N
)
IRST
AME
IDDLE
AME
AST
AME
(A
1)
DDRESS
(A
2)
DDRESS
(C
,
S
,
Z
)
ITY
TATE
IP
Do solemnly swear as follows:
1.
That my name is ………….…………………….….…………………………………………………………………………..
(F
)
(M
)
(L
)
IRST
IDDLE
AST
2.
That I am a citizen of G
, having been born in the Parish of
RENADA
…………………………………………….……….……….. on ………………………..…………………………….
(D
/
M
/
Y
)
AY
ONTH
EAR
3.
That I have not renounced my citizenship of GRENADA.
4.
(a) That Lost Passport No. …………………………………………….……….…… was issued to me
on/around …………………………………………….……….……………
(D
/
M
/
Y
)
AY
ONTH
EAR
(b) That I lived at
when the passport was issued to me.
5.
That I lost passport on/around
(D
/
M
/
Y
)
AY
ONTH
EAR
at
(P
W
P
L
)
LACE
HERE
ASSPORT WAS
OST