Republic of the Philippines )
Catarman Northern Samar ) S.S
                          AFFIDAVIT OF DESTRUCTION/MUTILATION
            I, Antonio C. Tobes Jr. , of legal age, single, Filipino citizen, and presently residing at
     Bobon, Northern Samar, 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 Department of Foreign Affairs 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 _______ 2018
     at __________________, Philippines.
                                                                    ________________________
                                                                             Affiant
            SUBSCRIBED AND SWORN to before me this ____ day of _________ 2018 in
     _______________, Philippines, affiant exhibiting to me his/her competent evidence of identity by
     way of __________________ issued at ___________ on ________________.
     Doc No. : _____
     Page No.: ______
     Book No.: ______
     Series of 2018