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Republic of the Philippines )

City of San Fernando ) S.S.


Province of Pampanga )

AFFIDAVIT OF MUTILATION

I, _________________________________________, of legal age, _________, Filipino citizen,


and residing at __________________________________________________________________________,
after being sworn to before the law depose and state:

1. That I was issued a ________________________________________, issued by the


_____________________________, which expires on ______________________.
2. That I used to keep the said __________________________ in ___________________________
for safekeeping.
3. That unfortunately on ___________________, the said ____________________________ was
mutilated_____________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
________________________________________________________________________________________.
4. That I am now executing this affidavit to prove the facts mentioned above
and for all intents and purposes necessary.

IN WITNESS WHEREOF, I hereby set my hand this ____ day of __________________,


20___ at ________________________________________.

__________________________________________
Affiant

JURAT

SUBSCRIBED AND SWORN to before me this ____ day of __________________ 20___ at


_______________________________________ by __________________________________ presenting
his/her _____________________________________ issued by _________________________________ and
valid until __________________.

Doc. No. _____;


Page No._____;
Book No._____;
Series of 20____.

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