Republic of the Philippines )

City of Caloocan ) S.S.

x-------------------------------x
AFFIDAVIT OF MUTILATION
I, , of legal age, single, Filipino citizen, and presently
residing at City of San Jose Del Monte, Bulacan, 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

by the Department of Foreign Affairs;

2. That the said passport was damaged/mutilated under the following

circumstances:
Sometime in year 2009, I inadvertently left my passport
on my bed within the reach of children. When I returned to my
bedroom, I discovered that its cover and pages were torn and
crumpled. The children in our house reached the same and
played with it.

3. That the damage on the said passport has rendered it unusable for
travel purposes and therefore I request the Department of Foreign
Affairs to issue a replacement passport in my favor; and

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

5. That I execute this affidavit in truth for all legal intents and
purposes.

IN WITNESS WHEREOF, I have hereunto set my hand this 16 th day

of November, 2016 at Caloocan city, Philippines.

Affiant

SUBSCRIBED AND SWORN to before me this 16th day of

November, 2016 in Caloocan city, Philippines, affiant exhibiting to me her
competent evidence of identity by way of ----------------.

Doc No. : _____

Page No.: ______
Book No.: ______
Series of 2016