EMBASSY OF THE REPUBLIC OF THE PHILIPPINES)

Consular Section ) S.S.

Amman, Hashemite Kingdom of Jordan )

AFFIDAVIT RE DAMAGED PASSPORT

I, , Filipino, of legal age, , presently
residing at , and with permanent
address in the Philippines at ,
after having been sworn in according to law, do hereby depose and state that:
1. I was issued on by the ,
in , a Philippine passport with serial number ;
2. The said passport was damaged on or about , because of the
following circumstances:

3. The damage to the passport issued in my name was inadvertent and unintentional;
4. I am executing this affidavit to declare the factual circumstances as to how said
passport was damaged beyond further use and to support my present application
for a new passport to replace the one that was damaged; and that
5. Each and all of the facts stated here are true and correct, and made with full
awareness that I may be held liable for perjury and have the passport issued in my
name cancelled if any misrepresentations or falsehoods are found to have been
made in this affidavit.
Further Affiant sayeth naught.
IN WITNESS WHEREOF, I hereby affix my signature to this affidavit, here at Consular
Section of the Embassy of the Philippines in Amman, Hashemite Kingdom of Jordan
on .

Affiant

SUBSCRIBED AND SWORN TO before me here at the Consular Section of the Embassy
of the Philippines in Amman, Hashemite Kingdom of Jordan, on .

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