Affidavit Concerning Circumstances Regarding The Loss Of Passport Page 2
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1
26.
That I reported the loss to the Precinct at
(A
L
P
)
DDRESS OR
OCATION OF
RECINCT
on …………………………………………………………………………….
(D
/
M
/
Y
)
AY
ONTH
EAR
A
C
S
P
TTACH A COPY OF THE
OMPLAINT
LIP FROM THE
RECINCT
7.
That my passport was lost in the following circumstances:
8.
That I have not surrendered the passport to any other authority or disposed of it in any
manner.
9.
That I promise to surrender the passport to the proper authority if it is subsequently found.
10.
That the above information is true and correct.
S
……………………………………………………..
IGNED
(A
)
PPLICANT
SWORN
B
M
T
…………………
D
…………………………………………………………….……………..
TO
EFORE
E
HIS
AY OF
(D
)
(M
)
(Y
)
AY
ONTH
EAR
………………………………………………………...
L
/
N
P
AWYER
OTARY
UBLIC
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