Republic of the Philippines )

City of Pagadian ) S.S.

Province of Zamboanga del Sur
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AFFIDAVIT OF MUTILATED PASSPORT

I, RANIL SAQUIN BASALO, of legal age, married, Filipino citizen, and presently
residing at Purok Basalo, Kapamanok, San Pablo, Zamboanga del sur, after having been
duly sworn to inaccordance with law, do hereby depose and say:

1. That I am a holder of Philippine Passport No. EC5147204 issued on 30 August 2015

by the Department of Foreign Affairs in Cagayan de Oro;

2. That the said passport was damaged/mutilated due to that I always put it at the back
pocket of my pants everytime I travelled from my home to other places.

3. That the damage on the said passport has rendered it unusable for travel purposes
and therefore I request the Deaprtment of Foreign Affairs (DFA) 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 23rd day of January 2020
at Pagadian City, Zamboanga del Sur, Philippines.

RANIL S. BASALO
Affiant

SUBSCRIBED AND SWORN to before me this 23rd day of January 2020 in Pagadian
City, Zamboanga del Sur, Philippines, affiant exhibiting to me his competent evidence of
identity by way of _______________ issued at ___________
on ________________.

Doc No. : _____

Page No.: ______
Book No.: ______
Series of 2020 Notary Public