REPUBLIC OF THE PHILIPPINES )

_________________________________) S.S

AFFIDAVIT OF DAMAGED PASSPORT

I, __________, Filipino, of legal age, single, presently residing at ______________,

after having been sworn in according to law, do hereby depose and state that:

1.) I was issued on ____________ by the Department of Foreign

Affairs in ___________, a Philippine passport with number
______________;

2.) The said passport was damaged on or about 15 August 2019,

because I was not able to remove the said passport contained in
a certain bag I own and subsequently, the same bag was included
in the laundry;

3.) The damage to the passport issued in my name was inadvertent

and unintentional;

4.) I am executing this affidavit to declare the factual circumstances

as to how said passport was damaged beyond further use and to
support my present application for a new passport to replace the
one that was damaged; and that

5.) Each and all of the facts stated here are true and correct, and
made with full awareness that I may be held liable for Perjury
and have the passport issued in my name cancelled if any
misrepresentations or falsehoods are found to have been made in
this affidavit.

IN WITNESS HEREOF, I have hereunto set my hand this ____ day of _________
2019 at ________________.
________________________
Affiant

SUBSCRIBED AND SWORN to before me this __________ at ___________,

affiant personally known to me and exhibiting to me his ID No_____________.

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