Affidavit of Destruction or Mutilation - Template Form Pro · PH-law

REPUBLIC OF THE PHILIPPINES    )
PROVINCE OF ________    )
CITY/MUNICIPALITY OF ________    ) S.S.

AFFIDAVIT OF DESTRUCTION OR MUTILATION
(Of Philippine Passport)

I, ________, of legal age, Filipino, single, and presently residing at ________, after having been duly sworn to in accordance with law, hereby depose and state that:

1. I am the registered owner and holder of Philippine Passport No. ________, issued on ________ at DFA Angeles, valid until ________ (the "Passport");

2. The Passport was destroyed or mutilated on or about ________ at ________, in the following manner and under the following circumstances, to wit:

________

3. The destruction or mutilation of the Passport was not done intentionally, willfully, nor with any fraudulent intent, but occurred purely by accident and without any fault, negligence, or design on my part;

4. The Passport was at all times in my custody and control, and the same was neither used, nor caused to be used, by me or by any other person in furtherance of any unlawful, fraudulent, or illegal purpose;

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7. I fully understand that any false statement or misrepresentation made herein shall render me criminally liable for perjury under Article 183 of the Revised Penal Code of the Philippines, and for such other penalties as may be provided by law; and

8. I hereby consent to the collection and processing of my personal data contained in this Affidavit by the Department of Foreign Affairs solely for the purposes herein stated, in accordance with Republic Act No. 10173 (the Data Privacy Act of 2012).

IN WITNESS WHEREOF, I have hereunto set my hand this ________ day of ________, 20________ at ________, Philippines.

________
Affiant

SUBSCRIBED AND SWORN to before me this ________ day of ________, 20________ at ________, Philippines, by affiant ________, who is personally known to me or who was identified by me through competent evidence of identity, namely their Driver's License No. ________, issued on ________ at ________, valid until ________, and who signed the foregoing instrument in my presence and acknowledged to me that the same is their free and voluntary act and deed.

WITNESS MY HAND AND SEAL on the date and at the place first above written.

________
Notary Public

Doc. No.: ________
Page No.: ________
Book No.: ________
Series of ________.