Republic of the Philippines )

Province of Cagayan )
Municipality of Alcala ) S.S.

AFFIDAVIT OF MUTILATION

I, ELISA G. ADECER, Filipino citizen, married, married, and a resident of

Carallangan, Alcala, Cagayan, after being duly sworn to in accordance with law,
deposes and states that:

1. That I was issued a Philippine Passport by the Department of Foreign

Affairs, Tuguegarao City;

2. However, said passport was damaged/ mutilated because it was

accidentally torn by one of my children;

3. That the damage on the said passport has rendered it unusable for travel
purposes and therefore I request the Department of Foreign Affairs to issue
a replacement passport in my favor; and

4. 3. That I attest to the veracity of the foregoing information.

IN WITNESS WHEREOF, I have hereunto set forth my hand this 29 th day of March
2022 in Alcala, Cagayan.

ELISA G. ADECER
Affiant
ID: PIC 3906-9768-1738-
7047

SUBSCRIBED AND SWORN to before me this 29 th day of March 2022 in Alcala,

Cagayan.

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Series of 2022.