Republic of the Philippines )

City of Tagum . . . . . . . . . . .)S.S

Province of Davao del Norte . )
X----------------- x

AFFIDAVIT OF MUTILATION OF PHILIPPINE PASSPORT

I, ____________________________________________ OF LEGAL AGE,

Filipino citizen, married/single with residence and postal address at
_____________________________________________________________
_________
After having been sworn to in accordance with law, do hereby depose and
state the following:

1. That I am a holder of Philippine Passport No.

_______________________________ issued on
___________________ 20____ by the
_________________________________
____________________________ in
__________________________________________

2. That I am applying for replacement of my mutilated passport.

3. That I have reported the mutilation of my Philippine Passport to
the Philippine Embassy in Kuala Lumpur.

4. That the circumstances surrounding the mutilation of my passport

are as following:

5. That I execute this affidavit for the purpose of giving true and
correct statement surrounding the mutilation of my passport.

IN WITNESS WHEREOF, I hereby affixed my signature

this December 3, 2019 in Tagum City, Davao del Norte, Philippines.

Affiant

SUBCRIBED AND SWORN TO before me this October 4, 2019 in

Tagum City, Davao del Norte Philippines, affiant exhibiting to me his
competent evidence of identity by way of Armed Forces of the Philippines with
ID No. R016-E-165394issued at Tagum City.

Doc. No. __________;

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