REPUBLIC OF THE PHILIPPINES NOT FOR SALE

DEPARTMENT OF FOREIGN AFFAIRS

AFFIDAVIT OF DESTRUCTION/ MUTILATION
DATE
Foreign Service Post: (Ex. January 01, 2012)

AFFIDAVIT OF DESTRUCTION/ MUTILATION

I, , Filipino citizen, of legal age, presently residing at

after having been duly sworn to inaccordance with the law, do hereby depose and say:

1. That the said passport was damaged/ mutilated due to

2. 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

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

IN WITNESS WHEREOF, I hereby affix my signature this day of

in the year in the .

Signature of Affiant over Printed Name

PHILIPPINE EMBASSY )
CONSULAR SECTION ) S.S.
__________________ )

SUBSCRIBED AND SWORN to before me this day of in the year

at the affiant having exhibited to me his/her passport no.

issued in on and valid until .

Doc. No.: _______________________

Service No.: _____________________
O.R. No.:________________________
Fee Paid: _______________________