I,
do solemnly and sincerely declare that the foregoing particulars stated in this declaration are
and I make this solemn declaration conscientiously believing the same to be true.
Made and subscribed this on
Day of
(Signature of the Applicant)
Full Name of the Applicant
Mobile Number
Phone Number
Email Address
Address in the USA
Surrender Certificate
Date:
This is to certify that Mr. / Ms.
has renounced his / her Indian Citizenship and acquired United States /Foreign Citizenship.
His/Her Indian Passport mentioned above has been cancelled and returned to the Passport holder.
(Signature and Stamp (Consulate Officer)
Note: The applicant is advised to retain this document for life long to avail consular services in future.
Name of Minor (s)
Date of Birth
Place of Birth US/Foreign Passport#
Date of Issue
Place of Issue
Names and full particulars of my minor children, if any, who are / were Citizens of India7.
Applicant's Date of Birth:6.
Father's Name5.
Place of Issue:
I hereby renounce my Citizenship Of India and surrender my Indian Passport Number :
Date of Issue
4.
dated
I have acquired US / Foreign nationality on and consequently have obtained US / Foreign passport #:3.
I am2.
I,
am of full age and capacity and was born at
on
1.
RENUNCIATION OF CITIZENSHIP OF INDIA ON ACQUISITION OF CITIZENSHIP OF ANOTHER COUNTRY
RENUNCIATION CERTIFICATE
Govt. Form Reference #
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signature
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