Deemed Surrender Certificate Form - Declaration Of Renunciation Of Citizenship Of India On Acquisition Of Citizenship Of Another Country

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Include an Affidavit
of Loss with this
Deemed Surrender
DECLARATION OF RENUNCIATION OF CITIZENSHIP OF INDIA ON
Certificate
ACQUISITION OF CITIZENSHIP OF ANOTHER COUNTRY
1. I _____________________________________________________ (here insert name and address of
declarant) am of full age and capacity and was born at (with Tehsil, District, State and Country)
______________________ on__________________.
2. I have/have not been married.
I have been married
3. I have acquired US/Foreign nationality on _______________ and consequently have obtained US/Foreign
passport no. : ______________ dated ________________.
Example: Name,
As this form is used if
4. I hereby renounce my citizenship of India
you became a
Date and Place of
naturalized citizen over
Birth, Current
10 years ago (and prior
5. Father's Name ________________________________
Nationality,
to June 1, 2010),
Passport Number
provide any details you
6. Applicant's Date of Birth: __________________________________
can about the Indian
Passport. Maybe look at
your citizenship filings
7. Names and full particulars of my minor children, if any, who are/were Citizens of India
to see a copy of your
____________________________________________________________________________
original Indian Passport
Number.
8. Particulars of last Indian passport (if available): ___________________________________________
I, ____________________________________________ do solemnly and sincerely declare that 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 __________________
Phone No:
Name:
555 123-4567
John Smith
E-mail:
Signature:
US Address:
123 Your Street, San Francisco
Deemed Surrender Certificate
Do not Fill Out the Section Below -
Date: _______________
Consulate Officer Will Fill This Out
This is to certify that Mr./Ms. __________________________________ has renounced his/her Indian
citizenship
and acquired ___________________ (name of the country) Citizenship.
Signature & stamp (Consulate Officer)

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