Mutilation

Republic of the Philippines )

City of ________ ) S.S.

x--------------------------x


AFFIDAVIT OF DESTRUCTION/MUTILATION


I, _________________, of legal age, single/married/widow, Filipino citizen, and presently residing at _____________________, after having been duly sworn to in accordance with law, do hereby depose and say:

  1. That I am a holder of Philippine Passport No. ______ issued on ___________ by the Department of Foreign Affairs in ___________;

  2. That the said passport was damaged/ mutilated due to _______________________________________________________.

  3. That the damage on the said passport has rendered it unusable for travel purposes and therefore I request the Philippine Embassy/ Consulate to issue a replacement passport in my favor; and

  4. That I attest to the veracity of the foregoing information.

IN WITNESS WHEREOF, I have hereunto set my hand this ____ day of ___________ 20____ in ____________, _____________, Philippines.

___________________________________

Affiant

SUBSCRIBED AND SWORN TO before me this _____ day of _________ at ________________ affiant exhibited to his/her competent evidence of identity by way of _________________ issued on __________________ in _______________, Philippines.


Notary Public

Doc. No. ______;

Page No. ______;

Book No. ______;

Series of ______;