LOSS OR THEFT OF PASSPORT (art.13 Law n.1185/67) The undersigned___________________________________________________ (Surname and Name) born at___________________________________________________________ (City/Town) (Country) on_____________________ residing __________________________________ ________________________________________________________________ (Full Address) declares and swears to the loss or theft of his/her passport No.__________ issuing Authority_________________________________place and date of issue _______________________________ date of expiry _____________________. (1) (Place) (Date) _______________________ ________________________________ (Signature) ________________________________ (1) Please give a brief account of how the said document was lost. I certify that the above form was signed in my presence by (name of person signing)________________________________ upon verification of his identity through exhibition of document____________________no._______________ issued by___________________on___________________. Place and date Signature of certifying officer Qualification and official stamp CAUTION: Under Section 25 of the Passport Act no.1185 of 1/11/1967 any person making an untrue statement for the purpose of procuring a passport is liable to paying a fine, unless the fact consists of a more serious offence. Under Section 26 of Act no.15, 4/1/1968 any person making false or misleading statements, forging documents and using false documents will be punished in conformity with Penal Law and all others Acts on the subject.