Republic of the Philippines ]

Santa Cruz, Laguna ] s.s.

AFFIDAVIT OF MUTILATION
I, ____________________________________, of legal age, Filipino citizen and with
address at __________________________________________, Sultanate of Oman, 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 ______________________________; which passport was
unintentionally mulitated without any fault whatsoever on my part.

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

_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________

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

Affiant further sayeth naught.

IN WITNESS WHEREFORE, I hereto affixed my signature this _______ day of

___________________ 2016 in Santa Cruz, Laguna.

EDUARDO GALLO LAM

Affiant

SUBSCRIBED AND SWORN to before me by the affiant with

_______________________I.D. No. ___________________ issued on
_________________ in ________________________.

Doc. No. _____; A T T Y. E M M A N U E L E . S A N D I C H O

Page No._____; NOTARY PUBLIC, COMMISSION UNTIL 31 DEC. 2016
Book No._____; NOTARY PUBLIC FOR THE PROVINCE OF LAGUNA
Series of 2016. PER NOTARIAL COMMISSION SP. PROC. NO. 164(15)
IBP O.R. No. 995689, 04 January 2016, Laguna Chapter
PTR O.R. No. 2967138, 04 January 2016, Laguna
Roll No. 42246, admitted to practice law on 9 May 1997
MCLE Compliance No. V-0015412, dated 6 March 2016