PHILIPPINE CONSULATE GENERAL)

LOS ANGELES, CALIFORNIA ) S.S.

U.S.A )

AFFIDAVIT EXPLAINING THE MUTILATION OF MY PHILIPPINE PASSPORT

I, ____________________________________, of legal age, Filipino citizen and with address

at __________________________________________________________, after having been duly

sworn to in accordance with law, do hereby declare under oath:

That I am a holder of Philippine Passport No. _______________________ issued on

___________________________ by the ___________________________________________________;

That the circumstances of the mutilation of my passport are the following:

That, I am executing this affidavit in order to attest the circumstances surrounding the
mutilation of the aforesaid passport for purposes of asking for the replacement/renewal of my
passport.

Affiant further sayeth naught.

________________________
Affiant

SUBSCRIBED AND SUBMITTED before me this ___________ day

of____________________________ 20 __, in ______________________________________________.