Republic of the Philippines)

Manila )s.s.

AFFIDAVIT OF MUTILATION

I, RONALD SALVADOR TAEZA, of legal age, Filipino Citizen, and a resident of

No. 615 T. Anzures St. Sampaloc, Manila, after having been duly sworn to in
accordance with law, do hereby depose and state:

(1) That I am a holder of Philippine Passport No. EB3763796 issued on

September 30, 2011 by the Department of Foreign Affairs and which will expire on
September 29, 2016;

(2) That my nephew, IMMANUEL JOHN NICER, who is a special child, played
the said passport which resulted it to get damaged/mutilated;

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

(4) That I attest to the veracity and truthfulness of the foregoing information.

IN WITNESS WHEREOF, I have hereunto signed this ___th day of _____ 2016,
at Manila, Philippines.

_______________________
RONALD SALVADOR TAEZA
Affiant

SUBSCRIBED AND SWORN TO BEFORE ME, this ____ day of ______ 2016 at
Taguig City, affiant exhibiting to me his PRC ID with No. 0872996 which will expire on
May 6, 2019 bearing his picture and signature thereon as a competent proof of his
identity.

Doc. No. ______;

Page No. _____: NOTARY PUBLIC
Book No. _____;
Series of 2016.