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

AFFIDAVIT OF DESTRUCTION/MUTILATION

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

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

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

3.Thatthe damage on the said passport has rendered it unusable for travel purposes andtherefore I request the Department of Foreign Affairs to issue a replacement passport inmy favor; and,

4. ThatI attest to the veracity of the foregoing information.

IN WITNESS WHEREOF, I have hereunto set my hand this ____ day of _______ 2014 at ______________, Philippines.

________________ Affiant

SUBSCRIBED AND SWORNto before me this ____ day of ______ 2014 in _________, Philippines,affiant exhibiting to mehis/her competent evidence of identity by way of _______________ issued at ___________ on________________.

Doc No. : _____ Page No.: ______ Book No.: ______ Series of 2014 Notary Public