REPUBLIC OF KENYA

IN THE MATTER OF STATUTORY DECLARATION ACT 15

LAWS OF KENYA
AFFIDAVIT
I, PERIS MUMBI, of post office Box 50864-00200, Nairobi within republic of Kenya,
holder of Identity Card Number 10645255 do hereby make Oaths and state as follows:-

1. THAT I am of sound mind hence competent to swear this affidavit.

2. THAT I my passport number is A1174495.

3. THAT my passport got lost in Dubai on March 29th 2016.

4. THAT the matter was reported at the Police Station where an abstract was issued.

5. THAT I therefore Request the Immigration Officer to issue me with another passport.

6. THAT I swear this affidavit conscientiously believing everything contained herein is

true and in accordance with Oaths and statutory declaration Act CAP 15 of the laws
of Kenya
Sworn at Nairobi by the said

PERIS MUMBI }
This…………day of………, 2016 }
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} DEPONENT
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BEFORE ME

COMMISIONER OF OATHS

DRAWN BY:
RAUTTA & COMPANY ADVOCATES
SONALUX HOUSE 3RD FLOOR,
NAIROBI