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									                        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 _____________________.

(Place)                                           (Date)
_______________________                           ________________________________


(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.

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