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Annex Ured

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ANNEXURE ‘D’

SPECIMEN DECLARATION BY APPLICANT’S PARENT(S) OR GUARDIAN FOR ISSUE OF


PASSPORT TO MINOR
(On plain paper)

I/We, parent(s) of minor child whose details are mentioned below solemnly declare and affirm as
under:-

Name of the minor child:………………………………..


Date of Birth:………………………………………………

Name of father……………..…………..… Name of Mother……………..…………..…


Citizenship………..…………..………….. Citizenship………..…………..…………..
Passport No…………………..………….. Passport No…………………..…………..
Contact No…………..…………..………….. Contact No…………..…………..…………..
Email ID……….…………..……………….. Email ID……….…………..………………..
Address……………………..……………… Address……………………..………………
……………………………………………….. ………………………………………………..
……………………………………………….. ………………………………………………..

1. That I/We am/are the mother/father/parents/guardians of the above minor child on whose
behalf I/We am/are submitting passport application vide ARN no...............................................

3. The minor child mentioned above is a citizen of India. I/We solemnly declare that he /she
has not lost, surrendered or has been deprived of his/her citizenship of India.

4. I/We undertake the entire responsibility for his/her expenses.

5. I hereby certify and undertake that if any information provided in the above declaration is
found incorrect or misleading, following action may be taken by the Passport Authority for:

a) Cancellation (impounding/ revocation) of the passport issued on the basis of this


declaration;
b) Initiating criminal proceedings under relevant provisions of Bharatiya Nyaya Sanhita, 2023
and the Passports Act, 1967

Signature of father/legal guardian..…………..… Signature of Mother/Legal Guardian……………..


Name of father……………..…………..…………….. Name of Mother……………..……………………...…
Passport no: (preferably)……………….………; or Passport no: (preferably)……………….………; or
Aadhaar Card No ……….……………….………; or Aadhaar Card No ……….……………….………; or
Voter ID Card No …………….………….………; or Voter ID Card No …………….………….………; or
PAN Card No.…………..…………..…….………; or PAN Card No.…………..…………..…….………; or
Driving License No.……….…………..………… Driving License No.……….…………..…………

Date:
Place:
Note:

1. Section 5 of the Passports Act 1967 read with Rule 5 of the Passports Rules, 1980
stipulates that Passport Authority may make all such enquiry and may require an applicant
to furnish such additional information, documents or certificates, as may be considered
necessary by the Passport Authority for the proper disposal of the application required.

*****

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