Sworn Statement Form - Philippine Embassy
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1PHILIPPINE EMBASSY
) S. S.
TEL AVIV, ISRAEL
)
SWORN STATEMENT
(SINUMPAANG SALAYSAY)
I, __________________________, Filipino, of legal age, single / married /widow /divorced, and presently
residing at ____________________________________________, after having duly sworn to in accordance with
the law depose and say:
1. That the following are the personal information about my identity;
DATE OF BIRTH: ____________
PLACE OF BIRTH:_______________
(
Araw ng Kapanganakan)
(Lugar ng Kapanganakan)
PASSPORT NUMBER:_____________
DATE OF ISSUE: _______________
(Bilang ng Pasaporte)
(Araw ng Pagkakaloob)
PLACE OF ISSUE: ______________
DATE OF ARRIVAL IN ISRAEL: _________
(Lugar ng Pagkakaloob)
(Araw ng pagdating sa Israel)
NAME OF PARENTS
(Pangalan ng mga Magulang)
FATHER: _______________________
MOTHER: ________________________
(Ama)
(Ina)
2. That the following are the circumstances regarding the loss of my passport.
(Na nawala ang aking pasaporte ayon sa sumusunod na salaysay.);
STATE THE CIRCUMSTANCES REGARDING THE LOSS OF YOUR PASSPORT USE
ADDITIONAL PAPER IF NECESSARY
. (ISALAYSAY KUNG PAANO NAWALA ANG PASAPORTE MO.
GUMAMIT NG KARAGDAGANG PAPEL KUNG KINKAILANGAN.)
(
3. That I made all necessary efforts to locate the missing passport.
Na ginawa ko ang lahat na
nararapat upang makita o maibalik ang nawawala kong pasaporte.);
4. That I executed this affidavit to inform the Philippine Embassy in Israel about the missing
.
passport and to request issuance of a new one in its place
(Na ginawa ko ang salaysay na ito upang ipaalam sa
Pasuguan ng Pilipinas sa Israel ang pagkawala ng aking pasaporte at upang mabigyan ako ng kapalit nito sa lalong
;
and
madaling panahon)
5. That I attest to the truth of the foregoing facts and I am fully aware that information contrary to
the above will constitute legal action against me.
(Na ang nasasaad sa itaas ay pawang katotohanan at anumang
taliwas sa nasaad ay nangangahulugang karampatang aksiyon laban sa akin.)
_____________________________
SIGNATURE (
)
Pirma
Affiant
SUBSCRIBED AND SWORN to before me this _________ day of ________ 20___ at the
Philippine Embassy in Tel Aviv, Israel.
Doc. No. ________
Service No. ________
Series of 20___
___________________
Fee: _________
Consular Officer
O. R. No.________
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