DECLARATION OF RENUNCIATION OF CITIZENSHIP OF INDIA

ON ACQUISTION OF CITIZENSHIP OF ANOTHER COUNTRY

1. I ________________________________________________________________________________________________________

______________________ (here insert name and address of declarant) am of full age and capacity and was born at (with Tehsil,

District, State and Country) _________________________ on ________________(date)

2. I have/have not been married.

3. I acquired US /Foreign Nationality on _____________ (date) and consequently have obtained US /Foreign passport no.: __________
dated ______________________.

4. I hereby renounce my citizenship of India and surrender my Indian Passport No.________________Date of Issue________________
5. Names and full particulars of my minor children, if any, who are/were Citizens of India

__________________________________________________________________________________________________________

I,__________________________________________________________ do solemnly and sincerely declare that the foregoing

particulars stated in this declaration are true and I make this solemn declaration conscientiously believing the same to be true.

Made and subscribed this __________________day of ________________

Name, Phone Number, Email address, US address:

________________________________________________________________________________________________________
_____________________________________________________________________________________________________

Signature: ____________________________

Documents Required:
1. Indian passport original along with a photocopy of first three and last two pages (if you do not have original passport, then
photocopy should be submitted along with the self-affidavit for Lost Indian Passport, If you do not have photocopy of Indian
passport also then state the same)
2. US naturalization Certificate copy
3. Photocopy of US passport (first two and last two pages and page containing any amendment)
4. Residence proof (Utility bill/driving license/lease deed)
5. Fees: US$ 175/- for those who acquired citizenship on or after 1 June 2010, others US$ 20/-
6. Mailing fees: US$ 20 (if you are seeking surrender certificate by mail)
(Note: fees should be paid only in form of cashier’ cheque/Money order/Postal Order while submitting application by mail and for
OCI card. You can pay cash at the counter for surrender certificate for all consular services except for OCI card)

Surrender Certificate
File No: Date:

This is to certify that

MR/Ms. _________________________________________________________________________ has renounced his/her Indian

citizenship and acquired ___________________ (name of the country) Citizenship. His/Her Indian Passport mentioned above has

been cancelled and returned to the passport holder.

Signature & stamp (Consular Officer)