REPUBLIC OF THE PHILIPPINES}

______________________________ } S.S.
______________________________ }

AFFIDAVIT OF MUTILATION

I, _____________________________, of legal age, married, Filipino

citizen and with postal and residential address at ____________________,
after having been sworn to in accordance with law, do hereby depose and
say:
1. That I am a holder of a Philippine Passport issued by
Department of Foreign Affairs with Passport No. ______________________;
2. That the said passport was damaged/mutilated under the
following circumstances;

Sometime in year ______, I inadvertently left my passport on

our table within the reach of my children. When I returned, I discovered
that several pages of my passport was marred by my children’s
handwritings.

3. That when I picked it up, it was too late to reverse any of the
damage and it was already unreadable;
4. That the damage on the said passport has rendered it unusable
for travel purposes and therefore I request the Department of Foreign
Affairs to issue a replacement passport in my favor; and
5. That I attest to the veracity of the foregoing information.
6. That I execute this affidavit in truth for all legal intents and
purposes.
IN WITNESS WHEREOF, I have hereunto affixed my signature this
_____th day of __________, here at ______________________.

_____________________________
Affiant

SUBSCRIBED AND SWORN to before me this ____th day of

___________________, here at ___________________

Doc. No.______;
Page No.______;
Book No. _____;
Series of _____.