Republic of the Philippines )

City of Iloilo ) S.S.

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

AFFIDAVIT OF MUTILATION OF PASSPORT

I, SHIELA GRACE FORNAL POMARIS, of legal age, single, Filipino citizen, and
presently residing at Cagban, Manocmanoc, Boracay Island, Malay, Aklan, 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. EC6829276 issued on 22 February

2016 by the Department of Foreign Affairs in Iloilo;

2. That the said passport was damaged/mutilated because my 5-year-old niece tore pages
15 and 16 and drew on some of its pages.

3. That the damage on the said passport has rendered it unusable for travel purposes;

4. That I am executing this affidavit to attest to the truth of the foregoing and for the purpose
of applying for replacement of the said mutilated passport.

IN WITNESS WHEREOF, I have hereunto set my hand this this 21st day of February
2018 in Iloilo City, Philippines.

SHEILA GRACE F. POMARIS

Affiant

SUBSCRIBED AND SWORN to before me this 21st day of February 2018 in Iloilo City,
Philippines, affiant exhibiting to me her competent evidence of identity by way of Voter
Certification with voter registration record number 0412300014532 issued at Malay, Aklan
on January 20, 2016.

Doc No. ______;

Page No.______;
Book No.______;
Series of 2018.