REPUBLIC OF THE PHILIPPINES)

CITY OF LAS PIAS

) S. S.
X -----------------X

AFFIDAVIT OF MUTILATION
I, , of legal age, Filipino, single and resident of after having been duly
sworn to in accordance with law, hereby depose and say that:
1. I am a holder and owner of Philippine Passport No. issued on July
8, 2010 with expiry date on July 7, 2015, issued by the Department of
Foreign Affairs, Cebu.
2. On or about last week, when I opened my passport, the binder
that holds together all the leaves or pages of said passport got detached
from its had front and back plastic covers, but the same passport is still
intact, with no data therein erased or lost.
3. The mutilation of said passport is unintentional and accidental, and
that the same passport is not, at the time of such mutilation, the subject of
any dispute, legal proceeding, confiscation by authorities for any unlawful
act, or act involving violation of existing immigration laws, the passport act
or any other laws; neither is myself the subject of any existing or threatened
legal action.
4. I am executing this affidavit to attest to the truth of the foregoing
facts for all its legal intents, effects, consequences and purposes, including
for the issuance to me of another Philippine passport in lieu of the
defaced/mutilated one which I am surrendering intact to the Department of
Foreign Affairs or the proper government agency.

AFFIANT
SUBSCRIBED AND SWORN to before me at Las Pias City this May 19,
2014 affiant with identification card: Passport No issued on July 8, 2010 with
expiry date on July 7, 2015, issued by the Department of Foreign Affairs,
Cebu.

Doc. No.
Page No.
Book No.
Series of 2014.