Republic of the Philippines)

City of Z A M B O A N G A ) S.S.

AFFIDAVIT OF DESTRUCTION/MUTILATION

I, JAMIR E. HASIM, of legal age, married, Filipino citizen, and presently residing at Zone
2, San Roque, Zamboanga City, after having been duly sworn to in accordance with law, do hereby
depose and state:

1. That on June 27, 2019 at around 1:40 in the morning our residence located at Zone 2, Barangay San
Roque, this City, was burned and destroyed by fire;

2. As a result of the fire, most of our belongings and personal properties including the following
important items were destroyed or lost, to wit:

JAMIR E. HASIM 1. Passport with no. EC7642913

2. Birth Certificate
3. Marriage Contract
4. IQAMA
5. Driver’s License- issued by Saudi Arabia
6. Insurance-BUPA Saudi Arabia
7. Mitsubishi Expander GLX1.5

ANALIZA A. HASIM 1. Passport

2. Birth Certificate
3. Student Driver’s License
4. Id’s

FATIMA AL-ZAHRA A.HASIM 1. Passport

AISHA A. HASIM 2. Birth Certificate
AMEER A. HASIM
OMAR A. HASIM

That I am executing this affidavit to attest to the truth of the foregoing narration of
facts and for whatever purpose this may serve.

IN WITNESS WHEREOF, I have hereunto set my hand on the date and place hereinafter
mentioned.

JAMIR E. HASIM
Affiant

SUBSCRIBED AND SWORN to before me on this _______ of July, 2019 at Zamboanga

City, Philippines.

DOC NO.________;
PAGE NO._______;
BOOK NO.______;
SERIES OF 2019.
That I am a holder of Philippine Passport No. EC7642913 issued on May 06,
2016 by the Department of Foreign Affairs in Zamboanga City;

2. That the said passport was damaged/mutilated during the fire incident last
June 27, 2019 at around 1:40 in the morning in our residents at Zone 2,
Barangay San Roque, this City .

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 _______ 2014 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 2014 Notary Public