I/We________ solemnly declare and affirms as follows:
1. That I/We am/are the mother/father/parents/guardians of ________ who is a minor child and on whose behalf ________. I/We have made an application for his/her passport.
2. Signature/Consent of Mr/Mrs________ who is father/mother/parents of the child has not ________ been obtained by me for the following reasons:
3. That I/We only am/are taking 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 the case and not the Passport Issuing Authority.
Signature & Address of the parent (s)/guardian(s) applying for the Passport