A F F I D AV I T

(TO EXPLAIN LOSS/DESTRUCTION OF PHILIPPINE PASSPORT)

AFFIANT: (Please type/print legibly all information requested)
NAME: _______________________________________________________________________
(First Name)
(Middle Name)
(Last Name/Surname)
Date of Birth: _______________________
______________________
Civil Status:

Place

of

Birth:

(___) Single
(___) Married
(___) Divorced
(___) Separated
(___) Widow (er)

Residence: ________________________________ Tel.# : _____________________________

Passport No. :_____________________ Date of Issue :_______________________________
Place of Issue:_________________________________________________________________
after being sworn according to law, depose and say:
1.

That I am a Philippine citizen and holder of Philippine passport described above:

2.

That the said passport was (check appropriate box) was (__) lost (__) destroyed
under the following circumstances
(State when, where and how passport was lost or destroyed. If space below is not
sufficient, use reverse side):

___________________________________________________________________________________
__________________________________________________________________________________
__
___________________________________________________________________________________
___________________________________________________________________________________
3.

That efforts were exerted to locate the lost passport, but in spite of diligent
search, it could not be found and the same is now beyond recovery. (This
paragraph is not applicable to destroyed passport)

4.

That I need a new passport urgently for the following reasons:

__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

5.

That in view of the foregoing explanation, it is requested that a new passport be

issued to the undersigned, in lieu of the (__) lost (__) destroyed passport, subject
to compliance with prescribed requirements.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___________ at Vancouver,

B.C., Canada.
________________________
Affiant
SUBSCRIBED AND SWORN to before me this _____________________ at the Philippine Consulate
General, Vancouver, B.C., Canada.
AFFIANT exhibiting to me his/her identification document:
__________________________
Signing Officer
Doc. No.
Book No.
Page No.
Series
Service No.
Fee

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