AFFIDAVIT

FOR LOST AND DAMAGED PASSPORT

I, Dileep. G, son of K. Gopalakrishnan holder of Indian Passport NO. L3017625 issued at

Trivandrum on 12/07/2013 do hereby solemnly declare that my above mentioned Passport
is lost.

I am an Indian national and have not acquired nationality of any other country.
I have not lost, surrendered or been deprived of my Indian citizenship.
I have not obtained any other travel document.

Passport No. L3017625

Place of Issue Trivandrum
Date of issue 12/07/2013
Name Dileep Gopalakrishnan
Address Krishna Bhavan,
Edamon-34,
Punalur,
Kollam,
Kerala,
Pin: 691307

Tel(mobile) 7900790619
Email dileepmon2@gmail.com

The Passport was lost in the following circumstances: While travelling

I Dileep .G solemnly affirms and declares that the above statement is true.

Signature
Sworn and signed me this day of:

Date: 09/12/2020