AFFIDAVIT OF LOSS MUTILATION OF PASSPORT I Filipino years old single married widow widower and presently resident at by gtu20753



I, ____________________________, Filipino, ______ years old, single/married /widow/
widower, and presently resident at __________________________________________ with
telephone number _____________________ after having been duly sworn to before
competent authority hereby depose and say:

    1. That I was born in ______________________ on ________________;
    2. That my father’s name is _______________________ a citizen of
       ____________________ and my mother’s name is ____________________ a citizen
       of ___________________________;
    3. That I acquired my Philippine citizenship by birth/naturalization;
    4. That I am a holder of Philippine Passport No. ______________ which was issued on
       ______________________ in ____________________;
    5. That I arrived in Shanghai on ___________________ from _________________ as a
    6. That the circumstances about the loss/ mutilation of my Philippine Passport are as

    7. That unable to find said passport despite diligent search, I reported its loss to the
       Shanghai Police Force as evidenced by the attached Police Report and ;
    8. That I am executing this affidavit for the information of all the authorities concerned
       and for the purpose of applying for a new passport or travel document.

        IN WITNESS WHEREOF, I have hereunto affixed my signature on this __________
        day of ________________ 20____ in SHANGHAI.

Philippine Consulate General)
Shanghai, China             ) s.s

                SUBSCRIBED AND SWORN to before me this _______day of ________              __
20 _____ in Shanghai, China.

Doc. No. _______
Book No. _______
Page No.________
Series of ________
OR No. ________

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