"Year of the Bicentennial of Peru: 200 years of Independence"

COMMITMENT TO CANCELLATION OF QUOTES AND/OR FRACTIONATION

I, …………………………………………………………………………..………, with identification

document (PASS/CIP/CE/OTHERS), ……………………….……………., of nationality ………..
………., of legal age and domiciled in …………………………...…… ……………….
…………………. district of ……………………………….., province of …………..……………,
department of …………………………………………… ….………., with email:
………………………………..……………….., and Telephone/Cell Phone No.
………………………… …..

I undertake to pay all my installments and/or installments for the fine obtained by
………………………………………………………………………..……………… ,
(PERMANENCE
IRREGULAR, USE OF MORE THAN ONE NATIONALITY, ETI, PPJJ, EMP and/or
OTHERS), which I have expired since …... of ………..………….. of ………. until the present
date……. of …………………….., of ..…….., I go to the subdivision since I do not have the
necessary resources to pay the fine in full, for the reason of not having a stable job and my
desire to comply with the duty of every foreign citizen to be in order in relation to my
immigration status in this country.

Finally; I ask you to evaluate my immigration situation and requested subdivision, which will
help me have legal residence in the country and thus contribute to the Peruvian state.

What I ask you to take into consideration for the relevant actions and purposes.

If the statement is determined to be false, I submit to the civil, criminal and administrative actions
established by the National Immigration Superintendence.

Likewise, I declare that I am aware that the presentation of false documents or providing false data or
information in immigration procedures is punishable by expulsion, in accordance with the provisions of
article 58 of Legislative Decree No. 1350.

……………….., ….. of ………..………..of 20.....

PASS/CIP/CE/OTHERS No. …………………………

Email: …………………………………………………
Phone: ………………………………………..……