Republic of the Philippines)

City of Naga )S.S.

AFFIDAVIT OF LOSS

I, ________________, of legal age, Filipino, single/married, and a

resident of _____________________________, Philippines, after having
been duly sworn in accordance with law, hereby depose and
state:

1. That on ____________________ I was issued a Philippine

Passport bearing No. ________________ by the Department of
Foreign Affairs in Manila;

2. That recently I had tried to look for the said passport but the
same could not be found;

3. That despite diligent search and efforts to locate the said

passport, I could not find the same such that I now believe
that it is now lost beyond recovery;

4. As such, I am executing this Affidavit of Loss to attest to the

truth of the foregoing and to support the application for the
issuance of new one in lieu of the one which was lost.

IN WITNESS WHEREOF, I have hereunto set my hand this

_____________ at _____________, Philippines.

___________________________________
 SUBSCRIBED AND SWORN to before me this ______ day of
________________, 2017 in the City of Naga, Philippines, Affiant
exhibited to me his/her _________________________________________
for purpose of identification.

Doc No.
Page No.
Book No.
Series of 2017