Regional Passport Office, Panaji, Goa

Home | Forms Instructions | Weekly Bulletin | Status | Contact

AFFIDAVIT

 

                                                         (Annexure A)

Affidavit to be submitted by Illiterate Applicants

SPECIMEN AFFIDAVIT TO BE SUBMITTED BY ILLITERATE APPLICANTS
AS PROOF OF DATE OF BIRTH IN CASE NO OTHER DOCUMENT
MENTIONED AT PARA A(b) OF SECTION IV IS AVAILABLE
(To be executed on non-judicial stamp paper)

I.................................... S/o/W/o/D/o........................................... presently residing at ........................  hereby state as follows:
I was born on........................... (date) at............................ situated in the District .........................in the State of ..................................... I have no documentary proof in support of my place and date of birth.
I do not possess any educational qualification and I am an illiterate person.
I take oath and solemnly declare/affirm that the particulars furnished by me above are correct and that I have not concealed or misrepresented any facts.

Place..................
Date:..................

Verified on this.................. day of ..................... of the year .........................  A.D that the contents of my above affidavit are true and correct to the best of my knowledge and belief and nothing in material has been concealed there from.

The contents of the affidavit has been read out to me.

Deponent:
Attested:

Signature and Official seal of attesting authority

Note: Affidavit to be attested by a magistrate/Notary.

 

Top

 

                                                      (Annexure B)

No Objection Certificate

ALL CENTRAL GOVERNMENT  EMPLOYEES,
STATE GOVERNMENT EMPLOYEES,  EMPLOYEES OF
STATUTORY BODIES AND PUBLIC SECTOR UNDERTAKINGS
ARE REQUIRED TO PRODUCE  A NO OBJECTION CERTIFICATE
(on Official Stationery)


Certified that Sri/Smt/kum............................... is a temporary/permanent employee of this  ..................................................................... (office address) from.................. (date), and  is at present holding the post of ............................. This Ministry/ Department/Organisation  has no objection to his acquiring Indian Passport. The undersigned is duly authorised to sign this No Objection Certificate.

Date: Name and Designation
Tel. No.:

 

Top

                                         

    

                                                      (Annexure C)

Intimation by an employee to employer

INTIMATION BY AN EMPLOYEE TO HIS EMPLOYER OF HIS INTENTION TO APPLY FOR PASSPORT

(for all central government employees, state government employees, employees of statutory bodies and public sector undertakings who are not producing a no objection certificate.)

(on official stationery)
Certified that  I Sri/Smt/kum............................... am a  a temporary/permanent employee of this  ..................................................................... (office address) from.................. (date), and  is at present holding the post of ............................. I have intimated my employer of my intention to apply for a passport.

 

Date: Name and Designation
Tel. No.:

 

Signature & Seal

The Head of Office

(in acknowledgement of the reciept of the said intimation)

Top

 

                                                 ( Annexure D)

Affidavit to be submitted with the application for a passport of a
minor child by either parent (who are separated but not formally divorced) 

SPECIMEN AFFIDAVIT TO BE SUBMITTED WITH THE APPLICATION FOR A PASSPORT OF A
MINOR CHILD BY EITHER PARENT (WHO ARE SEPARATED BUT NOT FORMALLY DIVORCED) OR BY A SINGLE PARENT OF THE CHILD BORN OUT OF WEDLOCK
(To be executed on non-judicial stamp paper)

I......................... (Name of the single parent) solemnly declare and affirm as follows :

  1. That I am the father/mother of ....................... (Name of the minor) who is a minor child and on whose behalf  I  have made an application for his/her passport.
  2. That I am judicially separated from the mother/father of ..............................(name of the minor)

   OR

          That no legally valid marriage ever existed between me      and Mr./Ms.(the father/mother         the minor child)........................................

OR

The father/mother of (name of the child).............has deserted me after conception/delivery.

      3. That .................. (name of the minor) is exclusively under my care and custody since separation.

      4. In case of Court case arises he/she would be responsible and not the Passport issuing Authority.

Date :                                                                                   Signature & address of Deponent

This affidavit be sworn before the First Class Judicial  Magistrate/Notary Public.

Top

                                        ( Annexure- E)

Affidavit To Be Submitted Along with Application For Passport By A Woman Applicant For Change Of Name After Marriage

SPECIMEN AFFIDAVIT TO BE SUBMITTED ALONGWITH APPLICATION FOR PASSPORT BY A WOMAN APPLICANT FOR CHANGE OF NAME AFTER MARRIAGE (JOINT AFFIDAVIT TO BE SUBMITTED ALONGWITH HER HUSBAND)
(To be executed on non-judicial stamp paper)

We  1. .................................................................... (Maiden name of wife)
       2. .................................................................... (Name of husband)

solemnly declare and affirm as under :

  1. That we are married under ........................ Marriage Act/Rights/Customs and are living together as married couple since ................. (date of marriage)                                                                                       
  2. That .......................................... (maiden name of wife) would henceforth be known as ...............................(name of wife after marriage) by virtue of our marriage.                                                                                                          
  3. That our joint photograph is affixed below.

                                                                                               

Date :                                                                                                    Signature of Deponent

                                                                                                            1................................
                                                                                                            2................................           

                                                                                                                           

Note :
1. This affidavit may be sworn before a Magistrate/Notary.
2. The joint photograph of the couple is to be pasted on the bottom left hand side of the affidavit paper and attested by the magistrate with his/her signature and rubber stamp (half on the photograph and half on the affidavit).
 

3.Declaration 2 above to be ignored by applicants who seek endorsement of name of spouse in respect of reissue of a previously issued passport.

Top

                                       ( Annexure - F)
Change in Name/Deed Poll/Sworn Affidavit

 

SPECIMEN AFFIDAVIT FOR CHANGE IN NAME/DEED POLL/SWORN AFFIDAVIT
(On Non-judicial stamp paper)

By this deed I, the undersigned.................................................. (New Name) previously called ............................................................. (old name) , doing  ........................................ (give profession or vocation) and resident of  ............................ (address) solemnly declare:-

  1. That for and on behalf of Myself and My wife and children and remitter issue wholly renounce/relinquish and abandon the use of my former name/ surname of ................... and  in  place thereof I do hereby assume from this date the name/surname ................. and so that I and my wife and children remitter issue may hereafter be called, known and distinguished not by my former name/surname. but by assumed name/surname of   .....................................

  2. That for the purpose of evidencing such my determination declare that I shall at all times hereafter in all records, deeds and writings and in all preceedings, dealings and transactions, private as well as upon all occassions what-so-ever use and sign the name of ..................... as my name/surname in place and in substitution of my former name /surname.

  3. That I expressly authorize and request all persons  in  general and  relatives and friends in particular, at all times hereafter to designate and address me, my wife, my children. remitter issue by such assumed name/surname of .......................................... accordingly.

  4. In witness whereof I have here unto subscribed my former and adopted name/ surname of .............................................................. and ............................... affix my signature and seal. if any, this ............................ day of ...............................

Date ........................

Signed sealed and delivered by the above name
Former name ...................................................

In the presence of   .............................................  

Name     .....................................
Address ......................................

 

Name
Address

(This deed poll/affidavit may be signed and attested in presence of a Magistrate/Notary or Consular Officer in an Indian mission abroad)

Note:
In case of change of name, applicant should insert advertisements in two reputed newspapers (one local newspaper of the area in which he/she is residing and 2nd in Newspaper of the area of permanent address) and submit original newspapers at time of applying for passport in his/her new name.

 

Top

                                                      ( Annexure - G)

Verification Certificate 

SPECIMEN VERIFICATION CERTIFICATE

(on official stationery of verifying authority)

Reference  Number                                                                          (Applicant's Photo)

                                                                                                                                 

This is to certify that Mr/Miss/Mrs........................ S/o/D/o/W/o ...................................... whose personal particulars are given below has good moral character and reputation and that after having read the provisions of section 6(2) of the Passports Act. 1967 (Printed below). I  certify that these provisions are not  attracted   in  case  of  this   applicant    and  I,recommend issue  of  an Indian passport to  him/her. Applicant has been staying  at his/her address continuously for the last one year.

Date of Birth:
Place of Birth:
Educational Qualification:
Profession (Govt./Private Service/Others)
Present Address:
Permanent Address:
 

Place:
Office address with location

Date:                                              (Office Seal)   

Signature:
Full Name:
Designation:
I Card No:
                                      (Enclose a Photocopy of I card):
Tel No.Office:
Tel No Residence:


(Photograph of applicant to be pasted here. Applicant should sign across the photograph)


Note:

  1. The applicant's Passport size photograph is also required to be affixed on the verification Certificate and attested by the officer issuing the Verifying Certificate with his/her signature and rubber stamp in such a way that half the signature and stamp appear on the photograph and half on the certificate.

  2. If applicant has resided at more than one place during the last one year then all previous addresses with the relevant dates should be mentioned.

  3. This verification certificate may be got signed by any of following:
    (i) A Deputy Secretary/ Director/ Joint Secretary/ Add Secy./ Spl. Secy./ Secy./ Cab.Secy. to the Govt. of India.
    (ii) A Joint secretary/ add. Secy / Spl. secy./ Secy./ Chief Secy. to a state Govt.
    (iii) A Sub-Divisional Magistrate/ Additional DM/ District Magistrate of the district of residence of applicant.
    (iv) A District Supt.of Police/Range, DIG/ IG/ DGP of district of residence of applicant.
    (v) A Colonel and above or equivalent ranks in the Air Force and the Navy
    (vi) The General Manager of a Public Sector Undertaking.
    (vii) All members of any All India Service or Central Service who are equivalent to or above the rank of a Deputy Secretary to the Government i.e. in the pay scale of Rs.12,500-16,000 or above.
    (viii) Resident Commissioners/Additional Resident Commissioners to state Governments based in Delhi.

  4. Anyone who issues incorrect verification certificate may be prosecuted under section 12 (2 ) of the passports Act. 1967.

  5. SECTION 6(2) OF THE PASSPORTS ACT. 1967.

    "Subject to the other provisions of this Act, . the passport authority shall refuse to Issue a passport or travel document for visiting any foreign country under clause (C) sub-section 5 of any one or more of the following grounds. and on no  other grounds namely:-


    (a) That the applicant is not a citizen of India.

    (b) That the applicant may, or is likely to engage outside India in activities prejudicial to the sovereignty and integrity of India.

    (c) That the departure of the applicant from India may, or is likely to, be deterimental to the security of India.

    (d) That the presence of the applicant outside India may, or is likely to prejudice the friendly relations of India with any foreign country.

    (e) That the applicant has, at any time during the period of five years immediately preceding the date of his application been convicted by a court in India for any offence involving moral turpitude and sentenced in respect thereof to imprisonment for not less than two years.

    (f) That criminal proceedings in respect of an offence alleged to have been committed by the applicant are pending before a court in India

    (g) That a warrant or summons for the appearance, of a warrant for the arrest, of the applicant has been issued by a court under any law for the time-being in force or that an order prohibiting the departure from India of the applicant has been made by any such court.

    (h) That the applicant has been repatriated and has not reimbursed the expenditure incurred in connection with such repatriation.

Top

 

                                                        ( Annexure - H)

DECLARATION OF PARENTS/SINGLE PARENT OR GARDIAN IF PASSPORT IS FOR MINOR: TO BE SIGNED BY BOTH THE PARENTS/SINGLE PARENT OR GARDIAN


I/We affirm that the particulars given above are in respect of (name of the child) ........................................................ son/daughter of Shri........................................................... and Smt. ..................................................... of whom I/We am/are the parents/single parent/Guardians. I/We undertake the entire responsibility for his /her expenses. I/We solemnly declare that he/she has not lost, surrendered or been deprived of his/her citizenship of India and that the information given in respect of him/her in this application is true. It is also certified that I/we am/are holding/not holding valid Indian Passport(s) and the name of the child mentioned is not included in Passport of either parent.

Details of passport(s) held by the both or either parent:

                                    (father)                                      (mother)
Passport No:....................................................      ......................................................................... (in case bothe parents do not hold passports , please write (NO)  )
Date & Place of Issue:  ......................................................................................
Child's name included in Mother's/Father's passport....................................................on page No........................................

                        AND/OR                                                                OR

(Signature)                                                    (Signature)                            (Signature)
Mother                                                          Father                                   Gaurdian

Name & Signature/T.I of both the parents/Single Parent/Gaurdian.(Left hand T.I if male and Right hand T.I  if female)

Top

 

Affidavit for a Passport in Lieu of Lost / Damaged Passport

SPECIMEN OF AFFIDAVIT TO BE SUBMITTED WITH THE APPLICATION FOR
A PASSPORT IN LIEU OF LOST/DAMAGED PASSPORT
(To be executed on non-judicial stamp paper)

(This affidavit is to be Executed on non-judicial stamp paper of appropriate value in the presence of magistrate first Class on the following points)

I .................................S/o/d/o/w/o/............................. residing at............ solemnly affirm as follows :

  1. State how and when the passport was lost/damaged and how many passports were lost/damaged Earlier ?

  2. State whether you travelled on the lost/damaged Passport if so. state flight number last date and port of entry into India?

  3. State whether you availed of any TR concessions/FTs allowance and if so details thereof?

  4. State whether non-resident Indian and if resident abroad. the details of the residence as Follows:

SI.
No.
Name of the
Country
length of residence
From     To        
(details if available)
Page Nos. of passport
bearing  departure & arrival stamps

1

2

3

     

 

I further affirm that I will take utmost care of my passport if issued and the Government will be at liberty to take any legal action under the Passport Act, 1967,if the lapse is repeated.

Date Deponent
Affirmed before First Class Magistrate


Top

.