REPUBLIC OF THE PHILIPPINES)

PROVINCE OF ALBAY ) S.S.

TABACO CITY )
x------------------------------------------x

AFFIDAVIT OF DESTRUCTION/MUTILATION

I, _________________, of legal age, single/married/widow, Filipino citizen, and

presently residing at _____________________, after having been duly sworn to in
accordance with law, do hereby depose and say:
1. That I am a holder of Philippine Passport No. ______ issued on ___________ by
the Department of Foreign Affairs in ___________;
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 and therefore I request the Philippine Embassy/ Consulate 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 ____ day of ___________
20____ in ____________, _____________, Philippines.

___________________________________

Affiant

SUBSCRIBED AND SWORN TO before me this _____ day of _________ at

________________ affiant exhibited to his/her competent evidence of identity by way of
_________________ issued on __________________ in _______________,
Philippines.

ATTY. ANTHONY CLARK A. GAPIDO

Notary Public Tabaco City
For the Province of Albay
Roll No. 83746
IBP OR No. 227570; June 13, 2022
PTR No. 8843533; July 13, 2022 at Tabaco City
MCLE: N/A (Newly Admitted to the Bar)
2nd Floor Coastal Building Rental, Purok 2,
Morales Street, San Roque,Tabaco City, 4511

Doc No.____;
Page No. 450;
Book No. 35 ;
Series of 2022