Republic of the Philippines )

Province ___________ )
___________ )S.S.

AFFIDAVIT OF MUTILATION and

UNDERTAKING

I, _______, of legal age, married, Filipino, and a resident of

_____________, after having been duly sworn to in accordance with law hereby
depose and state that:

1. I am a holder of Philippines Passport with Passport No. ___________,

issued by the Department of Foreign Affairs on March 4, 2010 which
expires on March 3, 2015;

2. Last May 12, 2015, I was preparing my personal papers and documents
including my passport in preparation of my papers to file my application to
work as OFW abroad;

3. I was busy attending to the things I have been doing when my son
scratched my passport with a ballpen rendering my passport to be
mutilated;

4. Some pages of my passport rendered the same mutilated;

5. The mutilation or destruction of my passport was purely accidental;

6. Hence, I am applying for a new passport in lieu of the mutilated one.

7. I am executing this Affidavit to attest to the truthfulness of all the foregoing

facts and for all legal intents and purposes it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this 10 th day of

June, 2015 at ______________

___________________
Affiant

SUBSCRIBED AND SWORN to before me this 10th day of June, 2015 at

____________