I, , Filipino, of legal age, single, married divorced by qyz12567

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									EMBASSY OF THE REPUBLIC OF THE PHILIPPINES                           )
TOKYO, JAPAN                                                         ) S.S.

                                          AFFIDAVIT OF MUTILATION

        I,_____________________________________________________, Filipino, of legal age, single,
       Ako                                                                                 Pilipino, may sapat na gulang
married / divorced / widowed, with present address in Japan at __________________________________
walang asawa/may asawa/diborsyado/byudo/byuda, may permanenteng tirahan sa Bansang Hapon sa
____________________________________________ and with telephone no. _____________________
                                                                  at may telepono bilang
after having been duly sworn to in accordance with law do hereby depose and say:
pagkatapos makapanumpa ng sang-ayon sa batas, ay malaya at kusang-loob na dito ay nagsasalaysay:

        That I am a holder of Philippine Passport No. _______________ issued on __________________
        Na ako ay nabigyan ng Pasaporte ng Pilipinas na may Bilang                   ipinagkaloob noong
at _________________________.
sa

        That my passport was mutilated due to the following circumstances:
        Na ang aking pasaporte ay nasira dahil sa mga sumusunod na pangyayari:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
        Na ginagawa ko ang salaysay na ito alinsunod sa mga kinakailangang dokumento ng Embahada ng Pilipinas,
        That I am executing this affidavit to attest to the facts of the foregoing in compliance with the
Tokyo para sa aking pag-apply ng panibagong pasaporte.
requirements of the Philippine Embassy in Tokyo in connection with my application for a new passport.

        AFFIANT FURTHER SAYETH NAUGHT.

        Sa katunayan ng lahat ng ito, ako ay lumagda ngayong ika-                                                          ng
        IN WITNESS WHERE OF, I have hereunto affixed my signature this ___________ day of
                                                sa Embahada ng Pilipinas, Tokyo, Japan.
________________________ 20_____ at the Philippine Embassy, Tokyo, Japan.

                                                                    ____________________________
                                                                               Affiant
                                                                                 Nagsasalaysay

        NILAGDAAN at SINUMPAAN sa harap ko, ngayong ika-                             ng                                    sa
        SUBSCRIBED AND SWORN to before me this _______ day of ________________ 20 _____in
Tokyo, Japan, ipinakita ng nagsasalaysay ang kanyang Pasaporte ng Pilipinas Bilang                      ipinagkaloob noong
Tokyo, Japan, affiant exhibiting his/her Philippine Passport No. _________________________ issued on
                                           sa
______________________________ at ______________________________.

Document No.     :______________
Service No.      :______________
Series of        :______________
Fee Paid         : ¥3,250
O.R. No.         :______________

								
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