FORM - XIX CITIZENSHIP ACT, 1955-SECTION 5(l)(e)





[Rule 16A]



1. I, A-B, (here insert address of the applicant showing district and name of the State) am of full age and capacity and was born at (with place and country) on……….

2. My father’s full name is/was………………… and he was born at……………………

3. am single /married /widower /widow /divorced from my wife /husband……………

4. My wife’s/husband’s full name is/was……………………..

5. My age on the date of application is……………………..

6. Marks of identification……………………..

7. Date of first arrival in India………………………

8. Particulars of residence in India with addresses………………………….

Address

From date

To date

Year

Month

9. I am a citizen of my passport/naturalisation certificate/registration certificate as a citizen of was issued at on day month years.

(Here write place and date of issue)

10. (a) I have not been away from India throughout the twelve months immediately preceding the date of application.

(b) I have resided in India during the twelve years immediately preceding the date of this application for periods amounting in the aggregate to not less than eight years.

(c) I intend to reside permanently in India.

11. Profession or occupation

12. The name of the employer, if any

13. Passport particulars, if any:

(a) Number

(b) Place and date of issue

(c) Name of issuing authority

14. Description of immovable property and/or business interests in India abroad.

Place

Brief description of property business / interests

At present in possession of

15. Details of family members who are staying with the applicant in India

Name

Present address

Relationship

Age

16. Details of members of family in a country other than India.

Name

Present address

Relationship

Age

17. Give details of all proceedings of any kind (civil or criminal) take against you in courts of law.

Nature

Date

Place

Result

18. Names and addresses of two references in India to whom the applicant is well known:

(i)

(ii)

I, A-B do solemnly and sincerely declare that the foregoing particulars stated in this application are true, and I make this solemn declaration conscientiously believing the same to be true.

Signature…………………

Made and subscribed this…………………. day of………………. 19……… before me.

*Signature……………………………

*Designation…………………………

I, the undersigned, hereby state that I am an Indian citizen otherwise than by naturalisation; that I am a householder; and that I am not the solicitor or agent of……………. I vouch for the correctness of the statements made by………………… in the application for……………………..

Signature……………………..

Name (in BLOCK LETTERS)…….

Full postal address…………………………

………………………………………….

Oath of allegiance

1, A-B…………………….. do solemnly affirm (or swear) that I will bear true faith and allegiance to the Constitution of India as by law established, and that I will faithfully observe the laws of India and fulfill my duties as a citizen of India..

Signature…………………………

Designation……………………….

Affirmed/Sworn and subscribed this……………… day of…………………………. 19……………. before me.

*Signature: ……………………….

*Designation:……………………….

*Signature and designation of the officer authorised under rule 28 of the Citizenship Rules, 1956, before whom the registration, declaration or oath of allegiance is made or taken.