REPUBLIC OF KENYA

IN THE MATTER OF THE OATHS AND STATUTORY DECLARATIONS ACT

(CAP 15 LAWS OF KENYA)

AFFIDAVIT

I, ------------------------------------------ residing in Nairobi and of Post Office Box Number -------------

Nairobi in the Republic of Kenya herein, do hereby MAKE OATH and state as follows:-

1. THAT I am a Kenyan citizen residing in Nairobi within the Republic aforesaid. Annexed
hereto and marked “A” is a true copy of my birth certificate/ID/Passport No.---------------
issued on the --------------------.
2. THAT on or about the -------------------------, describe what happened to passport..

3. THAT I reported the matter to The Kenya Police on the ----------------------- and was issued
with an abstract confirming the same. Annexed hereto and marked “B” is a true copy of
the said abstract OB ------------------------------.

4. THAT I swear this Affidavit for the purpose of confirming that my passport ----------------is
lost/stolen etc and further in support of my application for a new passport.

5. THAT the facts deponed to herein are true and are within my own personal knowledge,
information and belief save and except where is otherwise stated.

SWORN by the said ------------------------- )

--------------- )
at Nairobi this day of )
2011 )
) _____________________
BEFORE ME: - ) DEPONENT
)
)
COMMISSIONER FOR OATHS )

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