RENUNCIATION CERTIFICATE DECLARATION OF RENUNCIATION OF CITIZENSHIP OF INDIA ON ACQUISITION OF CITIZENSHIP OF ANOTHER COUNTRY 1.

I _____________________________________________________ (here insert name and address of RILSA MELEDOM CHERIAN declarant) am of full age and capacity and was born at (with Tehsil, District, State and Country) KUWAIT CITY,KUWAIT MARCH 12 1986 ______________________ on __________________. 2. I not been married. I have/have have not been married 3. I have acquired US/Foreign nationality on _______________ and consequently have obtained US/Foreign passport no. : ______________ dated ________________.

E6624376 4. I hereby renounce my citizenship of India and surrender my Indian Passport No: ______________ Date of Issue: ____________Place of Issue: _________________

CHUMAR MELEDOM 5. Father’s Name: ______________________ 03/12/1986 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)

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