AFFIDAVIT OF DESTRUCTION/MUTILATION

I, Juan Dela Cruz, of legal age, male, Filipino, resident of Paombong, Bulacan,
after being sworn to in accordance with law, do hereby depose and say:

1. That I am a holder of Philippine Passport with no. P3333881A, issued

by the Department of Foreign Affairs on Sept. 29, 2018 which is valid
until Sept.20, 2028;

2. That sometime on March 2019, said passport was damaged due to

unauthorized unofficial stamp which was inadvertently done by my
person;

3. That the damage on said passport has rendered it unusable for travel
purposes and therefore I respectfully request that the Philippine
Embassy/Consulate to issue a replacement passport in my favor; and

4. As such, I am executing this affidavit to attest to the veracity of the

foregoing information.

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

____________ 2019 in ____________________, Philippines.

Juan Dela Cruz

Affiant
Phil. Passport No.
Issued on:
Issued by Department of Foreign Affairs (DFA)

_______________________ )
_______________________ ) s.s
_______________________ )

SUBSCRIBED AND SWORN to before me this ___ day of September 2019 at

_______________________________.

Date: __________
Service No. _____
O.R. No. _______
Fee paid: _______ (seal) ________________________________
Consul of the Republic of the Philippines