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 17TH 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. _____; A T T Y. E M M A N U E L E . S A N D I C H O

Page No._____; NOTARY PUBLIC, COMMISSION UNTIL 31 DEC. 2016
Book No._____; NOTARY PUBLIC FOR THE PROVINCE OF LAGUNA
Series of 2016. 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