RENUNCIATION DECLARATION

1. I _____________________________________________________ (here insert name andaddress of declarant) am of full age and capacity and was born at (with Tehsil, District, Stateand Country) ______________________ on __________________.

2. I have/have not been married.

3. I have acquired US/Foreign nationality on _______________ and consequently have obtainedUS/Foreign passport no. : ______________ dated ________________.

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

5. Father’s Name: ______________________

6. Applicant's Date of Birth: ___________________________

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

I, ____________________________________________ do solemnly and sincerely declare thatthe foregoing particulars stated in this declaration are true and I make this solemn declarationconscientiously believing the same to be true.

Made and subscribed this __________ day of __________________

Phone No: Name:E-mail: Signature:US Address:

RENUNCIATION DECLARATION

Date: ____________

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