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Instructions for filling the Affidavit

(For Status)

1. Witness should be:

a. Valid Indian Passport holder

b. Valid Green Card holder

c. Should not be a citizen of America

(Copies of (a) and (b) documents should be

notarized by Notary Public and submitted along

with the affidavit)

2. N/A should not be written anywhere. Complete and

correct information should be provided.

3. The affidavit, once completed, should be notarized

by Notary Public

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AFFIDAVIT

I, (name),_______________________________________________________________,

Son of__________________________________________________________________,

Residing at_____________________________________________________________________________________________________________________________________,

Date of Birth_____________, being an applicant for Issue of passport, do hereby

solemnly affirm and state as follows:

1. That the names of my parents and spouse are as follows (indicate full name);i. Father:

ii. Mother:

iii. Wife/Husband:

2. That I am continuously residing at the above mentioned address from_________________ (Date).

3. That I am a citizen of India by birth/descent/registration/naturalization and that I have

neither acquired the citizenship of another country nor have surrendered or been

terminated/deprived of my citizenship of India.

4. That I came to the USA illegally/legally on __________________.

5. That I do not have any legal status in the USA/I have legal status in the USA. (Please

mention the nature of status)___________________________________________________________________________________________________________________

6. Neither I, nor any of my family members have applied for obtaining political asylum

in the USA or any other country. (Clearly indicate here if you or any of your familymembers have applied for political asylum in the USA)________________________

_____________________________________________________________________

7. That I have not, at any time during the period of five years immediately preceding the

date of this affidavit, been convicted by any court in India for any offence involving

moral turpitude and sentenced in respect thereof to imprisonment for not less thantwo years;

8. That no proceedings in respect of any criminal offence alleged to have beencommitted by me are pending before any criminal court in India.

9. That no warrant of summons for my appearance, and no warrant for my arrest, has

been issued by a court under any law for the time being in force, and that mydeparture from India has not been prohibited by order of any such court.

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10. That I have never been repatriated from abroad back to India at the expense ofGovernment of India, but reimbursed expenditure incurred in connection with such

repatriation___________________________________________________________.

11. That I will not engage in activities prejudicial to the sovereignty and integrity of India

12. That my presence outside India will not prejudice the friendly relations of India with

any foreign country.

13. I am holder of Indian Passport No.____________ Issued at ____________________,

on_____________________, valid until____________________________________.

14. I could not apply for renewal/reissue of my passport in the prescribed period due

to___________________________________________________________________

_________________________________________________(Please state the reason)

15. Issue of passport/extension of validity of existing passport will facilitate in

regularization of my stay in the US. All efforts are being made by me to get my stayregularized.

16. I hereby undertake and agree that if the short validity passport issued to me is lost, Iwould not be granted further passport facilities and instead one way emergency

certificate would be issued to me.

Place: ___________________

Date: ___________________

Deponent

Witness 1

Signature________________________Name ________________________Address ________________________

________________________

Witness 2

Signature________________________Name ________________________Address ________________________

________________________

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