Republic of the Philippines ) Santa Cruz, Laguna ) S.S. x------------------------------------x
AFFIDAVIT OF IMPAIRMENT / MUTILATION I, ALBERT REYES CATARROJA, of legal age, married, Filipino citizen, and presently residing at Remedios Subdivision, Bubukal, Santa Cruz, Laguna 4009 Philippines, after having been duly sworn in accordance with law, do hereby depose and say: 1. That I am a holder of Philippine Passport No. EB4382752 issued on 05 January 2012 by the Department of Foreign Affairs in Metro Manila. 2. That the said passport was damaged, impaired and mutilated when it suddenly rained strongly while I was walking along the highway in Bubukal, Santa Cruz, Laguna about two weeks before I execute this affidavit. The said passport got drenched in rain-water while inside my cloth-bag that I was carrying at the time. 3. That the damage on the said passport has rendered it unusable for travel purposes and therefore I request the Department of Foreign Affairs of the Philippines to issue a replacement passport in my favor. 4. That I attest to the veracity of the foregoing information. IN WITNESS WHEREOF, I have hereunto set my hand this 17 TH day of September 2016 at Santa Cruz, Laguna, Philippines.
ALBERT REYES CATARROJA
Affiant
SUBSCRIBED AND SWORN to before me this 17th day of September 2016 in Santa Cruz, Laguna, Philippines, affiant exhibiting to me his competent evidence of identity by way of UMP Identification Card No. CRN-0111-0570333 issued at SSS Calamba City, Laguna, issued in the year 2012. Doc. No. _____; Page No._____; Book No._____; Series of 2016.
A T T Y. Y. E M M A N U E L E . S A N D I C H O
NOTARY PUBLIC, COMMISSION UNTIL 31 DEC. 2016 NOTARY PUBLIC FOR THE PROVINCE OF LAGUNA PER NOTARIAL COMMISSION SP. PROC. NO. 164(15) IBP O.R. No. 995689, 04 January 2016, Laguna Chapter PTR O.R. No. 2967138, 04 January 2016, Laguna Roll No. 42246, admitted to practice law on 9 May 1997 MCLE Compliance No. V-0015412, dated 6 March 2016
