Republic of the Philippines )

City of Iloilo ) S.S.

x----------------------------------x

AFFIDAVIT OF DESTRUCTION/MUTILATION OF PASSPORT

I, JICZ REID, of legal age, single, Filipino citizen, and presently residing at
Bacolod City, Philippines, 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. AB1234567 issued on by the

Department of Foreign Affairs, Bacolod City, Negros Occidental;

2. That the said passport was damaged/mutilated when I pulled it out its holder
with use of unnecessary force;

3. That by unintentionally doing so, some pages of the said passport were torn;

4. 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 favour; and

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

IN WITNESS WHEREOF, I have hereunto set my hand this 6 th day of June

2018, Iloilo City, Iloilo, Philippines.

JICZ REID
Affiant

SUBSCRIBED AND SWORN to before me a Notary Public commissioned in the

City and Province of Iloilo, Philippines this ____ of June 2018. Affiant
_____________________ appeared with his _______ ID with No.
_____________________________ issued by the _________________________ whom
personally known to be the same person to the Notary Public or identified by the
Notary Public through competent evidence of identity as defined by the 2004 rules
on Notarial Practice pursuant to Supreme Court EN BANC A.M. No. 02.8.13 SC
Resolution. That the herein person represented to the Notary Public that her
signature on the instrument or document was voluntarily affixed by her.

Doc. No. ______;

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