REPUBLIC OF THE PHILIPPINES) ________________________ ) S.S.

AFFIDAVIT OF LOSS
I, ___________________, of legal age, Filipino, married, and a resident of _______________________________, after having been duly sworn to in accordance with law, depose and state THAT: 1. On January 12, 2010, I was issued a Philippine Passport by the Department of Affairs in Manila; 2. Recently, I had tried to look for the said passport but the same could not be found; 3. Despite diligent search and efforts to locate the said passport, I could not find the same such that I believe that it is now lost beyond recovery; 4. As such, I am executing this affidavit to attest to the foregoing facts and to support the application for the issuance of a new one in lieu of the one which was lost. IN WITNESS WHEREOF, I have hereunto set my hand this ___________________ in Makati City, Metro Manila, Philippines.

______________________ Affiant ID No. _____________

SUBCRIBED AND SWORN TO before me this ____ day of ____________ 2014, in _____________________________, affiant exhibiting to me his valid proof of identification.

Doc. No. _____; Page No. _____; Book No. _____; Series of 2014.