RENUNCIATION CERTIFICATE

DECLARATION OF RENUNCIATION OF CITIZENSHIP OF INDIA ON

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. IPlease
have/have
not------>
been married.
Select
3. I have acquired US/Foreign nationality on _______________ and consequently have obtained
US/Foreign passport no. : ______________ dated ________________.
4. I hereby renounce my citizenship of India and surrender my Indian Passport No: ______________
Date of Issue: ____________Place of Issue: _________________
5. Fathers 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 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:
E-mail:
US Address:

Name:
Signature:

Surrender Certificate
Date: ____________

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

his/her Indian
citizenship and acquired ___________________ (name of the country) Citizenship.
His/Her Indian Passport mentioned above has been cancelled and returned to the
passport holder.
Signature & stamp (Consulate Officer)