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    Sample Affidavit of Mutilation

    Republic of the Philippines )
    City of ________            ) S.S.


                I_________________, of legal age, single/married/widow, Filipino citizen, and presently residing at _____________________, after having been duly sworn to in accordance with law, do hereby depose and say:

    1.  That I am a holder of Philippine Passport No. ______ issued on ___________ by the Department of Foreign Affairs in ___________;

    2.  That the said passport was damaged/mutilated due to ___________________ __________________________________________________.

    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.


                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                             

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