FORM IV (See rule 6) The Citizenship Act, 1955- section 5(4) APPLICATION FOR REGISTRATION OF A MINOR CHILD UNDER SECTION 5(4) OF THE ACT. Note: Please write/print in BLOCK LETTERS PHOTOGRAPH 1. (i) Full name of the minor child and the country of origin:............. (ii) If he/she has been known by another name, enter that name here: ............ (iii) Present address: ............ (iv) Occupation: ............ (v) Place and date of birth: ............ (vi) Nationality or citizenship at birth: ............ (vii) Present nationality, if different: ............ (viii) If stateless, state how nationality was lost: ............ 2.(i) Father's full name and the country of origin: ............ (ii) Nationality or citizenship: ............ 3.(i) Mother's full name and the country of origin: .............. (ii) Nationality or citizenship: ............ 4. Particulars of residence with address: (a) India From To Years Months (b) Other countries From To Years Months 5. The minor's intentions with regard to future residence, if this application is granted, are as follows: - 6. (i) Date of any previous application for naturalization or registration : (ii) Reference number, if known : (iii) Particulars of any change of nationality or of citizenship since birth : Nationality or citizenship acquired Date of acquisition (iv) Reasons for and the manner of change of nationality or citizenship: 7. Details of all proceedings of any kind (civil or criminal) taken against the minor in a court of law: 8. The minor's knowledge of a principal Indian language (to be mentioned) is slight/fair/good/excellent:........... 9. Reasons for which the applicant desires to acquire citizenship of India: ....... Nature Date Place Judgment of the Court 10. Names and particulars of near relations in India: S. No. Name Present Address Relationship Age Application 11. [Complete either (a) or (b) or (c) or (d) of this portion of application and cross out whichever sections are inappropriate]. The minor child (a) I,........ the minor child to whom the foregoing particulars relate, hereby apply for registration as citizen of India and attach the consent of any parent/guardian to this application. The parent who is a citizen of India (b) I, ........am a citizen of India and a parent of ......to whom the foregoing particulars relate. I hereby apply on behalf of my child for his/her registration as a citizen of India. The parent who is not a citizen of India (c) I,....am a parent of .....to whom the foregoing particulars relate and am a national/citizen of the State of .....and I hereby apply on behalf of ....for his/her registration as a citizen of India. The guardian (d) I, .......am the (sole) natural/appointed guardian of .....to whom the foregoing particulars relate, who has no living parent/whose parent or parents are living and resident in ..........I am duly authorized by the court or by the minor child's father (or mother in the event of his death) whose consent is attached, and I hereby apply on behalf of .......for his/her registration as a citizen of India. The reasons for this application are ................... Date:........ Signature of applicant......... Declaration 12. I do solemnly and sincerely declare that the particulars stated in this application are true and I undertake to inform the Secretary immediately, before the registration now applied for is effected if the particulars given above require amendment, in consequence of any change in (a) my circumstances; (b) the circumstances of the minor girl child and I make this solemn declaration conscientiously believing the same to be true. Signature of applicant ........ Minor child /Parent/Guardian Made and subscribed this .......... day of ......19..... before me. *Signature......... *Designation........ 13. I, the undersigned hereby state that I am a householder and an Indian citizen otherwise than by naturalization. I am not the solicitor or agent of .....and I vouch for his/her good character and loyalty. I support this application from personal knowledge of and intimate acquaintance with the applicant for .....years. Date ....... Signature............. Name ................ Full postal address......... ................. 14. I, the undersigned hereby state that I am a householder and an Indian citizen otherwise than by naturalization. I am not the solicitor or agent of ......and vouch for his/her good character and loyalty. I support this application from personal knowledge of and intimate acquaintance with the applicant for .....years. Date ........ Signature .............. Name ............... Full postal address ......... *Signature and designation of the officer authorized under rule 28 of the Citizen-ship Rules, 1956 before whom the Registration, declaration or oath of allegiance is made or taken.(i.e. the Collector, Deputy Commissioner, District Magistrate)
