Republic of the Philippines)

City of Cabanatuan . . . . . .. )S.S.

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AFFIDAVIT OF DAMAGED PHILIPPINE PASSPORT

I, EDNA BELMONTE BOLISAY, married, Filipino citizen, and with postal

address at No. 12, Blk 37, San Antonio Street, Brgy. Kapitan Pepe, Cabanatuan
City, Nueva Ecija after having been sworn to in accordance with law, do hereby
depose and state the following:

1. That I am a holder of Philippine Passport No. XX0691972 issued on

MARCH 07, 2008 by the Department of Foreign Affairs (DFA) in Manila;

2. That I am applying for replacement of my damaged and expired passport;

3. That I have reported the damage of my Philippine Passport to the DFA

Mobile Service conducted herein Cabanatuan City today, September 04,
2019;

4. That the damage of my passport was the result of the flood which
inundated the whole Province of Nueva Ecija including Cabanatuan City
caused by typhoon Lando and Nona in the year 2015;

5. That I am executing this affidavit for the purpose of giving true and
correct statement surrounding the damage/mutilation of my passport and
as a requirement for the replacement/renewal of the same.

IN WITNESS WHEREOF, I have hereunto signed my name, this

____ day of September, 2019 hereat Cabanatuan City.

EDNA BELMONTE BOLISAY

Affiant
ID No. CO5-96-1481
Issued By: LTO

SUBSCRIBED AND SWORN TO before me affiant personally appeared

with a valid proof if identity, details are written below her signature, this ______
day of September 2019 hereat Cabanatuan City.

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