Republic of the Philippines )

Catarman Northern Samar ) S.S

AFFIDAVIT OF DESTRUCTION/MUTILATION

I, Antonio C. Tobes Jr. , of legal age, single, Filipino citizen, and presently residing at
Bobon, Northern Samar, 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 Department of Foreign Affairs 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 _______ 2018
at __________________, Philippines.

________________________
Affiant

SUBSCRIBED AND SWORN to before me this ____ day of _________ 2018 in

_______________, Philippines, affiant exhibiting to me his/her competent evidence of identity by
way of __________________ issued at ___________ on ________________.

Doc No. : _____

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