I,…………………… ,
S/o ……………………………………………..,
Aged……………… years
presently and permanently
residing in………………………..\
do hereby solemnly affirm and declare as follows:—

1……………I was holding a Passport bearing No…… as issued from the
Regional Passport Office, on The expiry date of
my passport was

I lost my hand-bag containing the said Passport and other articles in the Central Reference Library of Delhi University on

An F.I.R. reporting the aforementioned loss was lodged by me with the
Police-station on the very same day. However,
the Police Authorities have been unable to recover my Passport and the accompanying articles till date and I have received no intimation whatsoever from the aforesaid authorities regarding the said loss.

4 I have used my Passport on two occasions – while travelling to Italy
from to , and while travelling to America
from to

I am a resident Citizen of India.

As I wish to travel to America next month for the purpose of attending a prestigious conference, I need a Passport as early as possible.

I undertake to keep the new Passport with utmost care and caution, failing which I will be liable to any legal action, which the Government may be pleased and authorised to take under the Passports Act, 1967.
Sd./ Deponent.

Verification

Verified at on this the day of ,
20 , that the contents of the above affidavit are true and correct to the best
of my knowledge, belief and information and nothing material has been concealed therefrom.
Sd./ Deponent.
Solemnly affirmed and signed before me by the deponent, who is personally
known to me, on this the day of ,20
Sd./ Notary.