SAMPLE FORM OF UNMARRIED DECLARATIONPARTICULARS REQUIRED FOR PRERAING AN AFFIDAVIT TO BE SUBMITTED
TO JAPANAESE WARD OFFICE
1. Full Name:___________________________________________________________________________________________
THENNAKOON MUDIYANSELAGE NIHAL KUMARA
2. Passport No:_______________________
Issued on________________
At__________________
N1234567
1988/08/12
COLOMBO
3. Date of birth: _________________4. Civil status: Bachelor/ Spinster / Widower / Divorcee
1978/01/28______________________________*please circle appropriate choice

5. Address in Japan:_________________________________________________________#507, GREEN HAITSU, 1-2-3, HIGASHI-GOTANDA,_________________________________________________________SHINAGAWA-KU, TOKYO

6. Address in Sri Lanka:_________________________________________________________
NO.14 DAMUNUWA, MAHARAGAMA, SRI LANKA_________________________________________________________

7. District: ___________________________
COLOMBO

A.G.A. Division: ___________________________
MAHARAGAMA

8. Full name of the father: __________________________________________________________
THENNAKOON MUDIYANSELAGE GAMINI9. Full name of the mother: _________________________________________________________
MALA PERERA
10. Parents’ address: _______________________________________________________________
NO. 16, DAMUNUWA, MAHARAGAMA, SRI LANKA
PARTICULARS OF THE INTENDED PARTNER
11. Full Name: ___________________________________________________________________________________________
KYOKO FUKADA
12. Passport No: ____________Dateof birth: 1982/11/02__________
TF1234567
13. Civil status: ______________________________
Spinster / Bachelor /Widower / Divorcee 14. Nationality: ____________________
JAPANESE*please circle appropriate choice

15. Address in Japan: _______________________________________________________________#1120, ROPPONGI HILLS TOWER MANSION, 4-5-6, ROPPONGI,MINATO-KU, TOKYO_______________________________________________________________
MASAHIKO FUKADA
16. Full name of the father: __________________________________________________________YURIKO FUKADA
17. Full name of the mother: _________________________________________________________#204, OUJI MANSHION, 1-2-3, OUJI-HONCHO, KITA-KU, TOKYO
18. Parents’ address: _______________________________________________________________
03-1234-5678______________________________ TEL No: ________________________
I hereby certify that the particulars given above by me are true and correct.
2020/06/24
Date: _________________________YOUR SIGNATURE
Signature: __________________________

SAMPLE FORM OF UNMARRIED DECLARATION

D E C

L A R

A T IONI,______________________________________________________________________
THENNAKOON MUDIYANSELAGE NIHAL KUMARA(Full Name of the Applicant)presently residing at ______________________________________________________#507, GREEN HAITSU, 1-2-3, HIGASHI-GOTANDA,
SHINAGAWA-KU, TOKYO (Applicant’s address in Japan)
And the son/daughter of Mr. _______________________________________________
THENNAKOON MUDIYANSELAGE GAMINI(Applicant’s Father’s Name)
And of Mrs. ______________________________________
of ____________________
MALA PERERA
NO. 16, DAMUNUWA,(Applicant’s Mother’s Name)(Address in Sri Lanka)________________________________________________________,
Sri Lanka holding
MAHARAGAMA(Address in Sri Lanka)
Sri Lanka passport bearing No. ______________________
issued at Colombo
N1234567(Passport No)
on ____________________________
do hereby declare that I am a ________________,
1988/08/12(Date of issue)(Civil status)born on ________________
1978/01/28 I have decided to marry Miss./Mr. ____________________
KYOKO FUKADA(Date of birth)___________________, presently residing at ___________________________________#1120, ROPPONGI HILLS TOWER(Address of intended partner)______________________________________________/ daughter ofMANSION,
4-5-6, ROPPONGI, MINATO-KU, TOKYOJapan, and the son__________*please circle appropriate choice

Mr. ___________________________and of Mrs. _______________________________
MASAHIKO FUKADAYURIKO FUKADA(Intended partner’s father’s Name)(Intended partner’s mother’s Name)
Residing at ______________________________________________________________#204, OUJI MANSHION, 1-2-3, OUJI-HONCHO, KITA-KU, TOKYO(Intended partner’s parent’s address)_____________ Japan, and who is a ______________nationalborn on ______________
JAPANESE
1982/11/02(Nationality)(Intended partner’s date of birth)and a___________ and under the existing laws of Sri Lanka, I truly and solemnly declare(Civil status of Intended partner)that my name and the contents of this declaration are true and correct.
Signature _________________________YOUR SIGNATURE
Date_________________________
2020/07/06