[Translator’s notes appear in square brackets]

[Personal information has been redacted.]


Letter of undertaking

I -----

Son of -----

Identification number -----

Place of issue -----

Born -----

For the reason of -----

I have resided in the country ----- as a refugee.


I declare my regret to have sought refuge from foreigners and undertake to refrain from repeating the above-mentioned act. To compensate for the past and pay my dues to the Islamic Republic of Iran, I will identify anti-revolutionary individuals and report their activities to the authorities.  In the event that the authorities of the Islamic Republic approve the issuing to me of a passport and exit permit, I shall be mindful of the interests of the Islamic Republic of Iran within or outside the country and will strictly refrain from any action against the principals of the Islamic Republic of Iran.


Signature and fingerprint

Address in Iran

Address abroad