AFFIDAVIT - Department of Foreign Affairs



A F F I D AV I T

(TO EXPLAIN LOSS/DESTRUCTION OF PHILIPPINE PASSPORT)

AFFIANT: (Please type/print legibly all information requested)

NAME: _______________________________________________________________________

(First Name) (Middle Name) (Last Name/Surname)

Date of Birth: _______________________ Place of Birth: ______________________

Civil Status: (___) Single (___) Married (___) Divorced

(___) Separated (___) Widow (er)

Residence: ________________________________ Tel.# : _____________________________

Passport No. :_____________________ Date of Issue :_______________________________

Place of Issue:_________________________________________________________________

after being sworn according to law, depose and say:

1. That I am a Philippine citizen and holder of Philippine passport described above:

2. That the said passport was (check appropriate box) was (__) lost (__) destroyed under the following circumstances

(State when, where and how passport was lost or destroyed. If space below is not sufficient, use reverse side):

___________________________________________________________________________________

____________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

3. That efforts were exerted to locate the lost passport, but in spite of diligent search, it could not be found and the same is now beyond recovery. (This paragraph is not applicable to destroyed passport)

4. That I need a new passport urgently for the following reasons:

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

5. That in view of the foregoing explanation, it is requested that a new passport be issued to the undersigned, in lieu of the (__) lost (__) destroyed passport, subject to compliance with prescribed requirements.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___________ at Vancouver, B.C., Canada.

________________________

Affiant

SUBSCRIBED AND SWORN to before me this _____________________ at the Philippine Consulate General, Vancouver, B.C., Canada.

AFFIANT exhibiting to me his/her identification document:

__________________________

Signing Officer

Doc. No. : _______

Book No. : _______

Page No. : _______

Series : _______

Service No. : _______

Fee : _______

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