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REPUBLIC OF THE PHILIPPINES }

QUEZON CITY, METRO MANILA } S.S.

AFFIDAVIT OF MUTILATION

I, JORGE ALFREDO LOPEZ III, of legal age, Filipino, married with residence address at
No. 42 Butterfly St., Valle Verde 6, Pasig City, after having been duly sworn to in accordance with
law hereby depose and state that:

1. That I am the owner/possessor of Philippine Passport issued by DFA NCR Northeast with
Passport No. EC1989223;

2. That April 4, 2019, when the above-mentioned passport was spilled by the coffee that I
was drinking, consequently, the same was considered as mutilated and rendered it invalid;

3. That I am executing this affidavit to attest to the truth of the foregoing and for whatever
legal purpose/s it may serve.

FURTHER AFFIANT SAYETH NAUGHT.

IN TRUTH THEREOF, I have hereunto set my hand this 11th day of April 2019, at Quezon
City, Philippines.

JORGE ALFREDO LOPEZ III


Affiant

SUBSCRIBED AND SWORN to before me this 11th day of April 2019, affiant exhibited
to me his/her Philippine Passport with No. No. EC1989223 issued by DFA NCR Northeast, issued
24 August 2014.

NOTARY PUBLIC

Doc. No. ___________;


Page No. ___________;
Book No. ___________;
Series of 2019.