I/We Shri _________ &/or Smt. _________ solemnly declare and affirms as follows:
1. That I/We, am/are the mother/father/Presents/Guardians of _________ who is a minor child and on whose behalf I/We have made as application for his/her passport.
2. Signature/Consent of Mr./Mrs. _________ who is father/mother/parents of the child has not been obtain by me for the following reasons:
3. That I/We only am/are talking care of _________ he/ she is exclusively in my physical custody.
4. I/We also affirm that in the case of a court case arising due to issue of a passport to the minor child _________.
I/We would be solely responsible for defending that case and not the passport issuing Authority.
Signature & Address of the Parents
_________ , _________