I, _________________, of legal age, single/married/widow, Filipino citizen, and presently residing at _____________________, 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 Philippine Embassy/ Consulate 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 _______ 2014 at ______________, Philippines.
________________SUBSCRIBED AND SWORN to before me this ____ day of ______ 2014 in _________, Philippines, affiant exhibiting to me his/her competent evidence of identity by way of _______________ issued at ___________ on ________________.