This statement needs to be completed only if the alien 12 years or older Attach File

Antecedents Statement
1. Statement
I declare that
 I have never been convicted of committing a crime to imprisonment or a custodial measure;
 I have never been committing a crime sentenced to re do unpaid work in the public interest or
community service;
 I have never been an unconditional fine imposed for committing a crime;
 I have never accepted a plea bargain for committing a crime;
 I have never been given a punishment for committing a crime;
 I am not at this time for committing a crime subject to prosecution;
 I have never been responsible for one of the following categories acts referred to in Article F of
the 1951 Refugee Convention: a crime against peace, a war crime, a crime against human hero, a
serious non-political crime (such as murder or terrorism) or acts contrary to the purposes and
principles of the United Nations (eg terrorist acts); and
 I am aware that a conviction for committing a crime can lead to refusal of stay or residence
termination.
 I have not submitted incorrect information during previous stay proceedings;
 I do not have stayed illegally in the Netherlands in verieden;
 Me no admission applies.

I can not explain to above for the following reasons

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2. Signature of the foreign

I have answered this statement truthfully

Name
Place and date Place Day Month Year
Signature

Pay attention!
Completing the antecedents statement contrary to the truth is an offense for which aangigte done in all
cases.