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REPUBLIC OF THE PHILIPPINES )
PROVINCE OF ________________________ )
CITY OR MUNICIPALITY OF ________________________ )S.S.
AFFIDAVIT OF DESTRUCTION OR MUTILATION
I, ________, of legal age, Filipino, single, and presently residing at ________, after having been duly sworn to in accordance with law, do hereby depose and state that:
1. I am the owner of a Philippine Passport which was issued at DFA Angeles (the "Passport");
2. The Passport was destroyed or mutilated in the following manner:
________
3. The destruction or mutilation of the Passport was not done intentionally or with any fraudulent intent, but occurred purely by accident and without any fault on my part;
I further undertake to surrender the destroyed or mutilated Passport to the Department of Foreign Affairs and to return the same should it be recovered or found at any later time.
________
Affiant
SUBSCRIBED AND SWORN TO BEFORE ME this _________ day of ______________________, 20______ at CITY OR MUNICIPALITY OF ________________________, ________________________ affiant, ________, personally appeared before me and exhibited to me their Driver's License no. ________ which is valid until ________.
Doc. No.: _________
Page No.: _________
Book No.: _________
Series of _________
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