Republic of the Philippines )

City of ________ ) S.S.

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

AFFIDAVIT OF DESTRUCTION/MUTILATION

I, _________________, of legal age,

single/married/widow, Filipino citizen, and presently residing at
_____________________, 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. ______ issued on

___________ by the Department of Foreign Affairs in ___________;

2. That the said passport was damaged/mutilated due to

___________________
__________________________________________________.

3. 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 favor; and,

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

IN WITNESS WHEREOF, I have hereunto set my hand this ____ day

of _______ 2018 at ______________, Philippines.

______________
__
Affiant

SUBSCRIBED AND SWORN to before me this ____ day of ______

2014 in _________, Philippines, affiant exhibiting to me his/her competent
evidence of identity by way of _______________ issued at ___________
on ________________.

Doc No. : _____

Page No.: ______
Book No.: ______
Series of 2018 Notary Public