AFFIDAVIT OF DESTRUCTION/ MUTILATION

I, __________________________________, Filipino citizen, legal age, presently residing at

__________________________________________________________________________________
after having been duly sworn to in accordance with law, hereby depose and state:

1. That I am a holder of Philippine Passport No. ______________________ issued on

___________________ at _____________________;
2. That the said passport was damaged/ mutilated due to
____________________________________________________________________
____________________________________________________________________
__________________________________________________________________
3. That the damage on the said passport has rendered it unusable for travel purposes;
4. That I am requesting the Philippine Embassy in Kuala Lumpur to issue a replacement
passport in my favor; and

5. That I attest to the veracity of the foregoing information.

IN WITNESS WHEREOF, I hereby affix my signature this day of ______________________ at

____________________________.

___________________________
Affiant
(Full Name and Signature)

SUBSCRIBED AND SWORN to before me this day of ___________________________, at

________________________ affiant exhibiting to me his/ her valid proof of identification.

Doc. No. : ________

Service No.: ________
Book No. : ________
Series of : ________ __________________________
Fee Paid : ________ Consular Officer
O.R. No. : ________