REPUBLIC OF THE PHILIPPINES)

CITY OF ROXAS . . . . . . . . . . . . . . . . ) S.S.

AFFIDAVIT OF LOSS

I,JUAN DELA CRUZ, of legal age, Filipino, single and a resident of

Magallanes St., Ilaya, Roxas City, Capiz, under oath, depose and state:

1. That, I was issued by the Department of Foreign Affairs,

Iloilo, a Philippine Passport, which is now expired;

2. That, when I looked for said passport in my envelop

where I normally place it, I could no longer find the same;

3. That, despite numerous diligent efforts to find the said

passport, I could no longer locate it up to the present and I
believe that it is already lost and beyond my recovery;

4. That, I execute this affidavit to attest to the truthfulness of

the foregoing facts.

IN WITNESS WHEREOF, I have hereunto affixed my signature this

________________ at the City of Roxas, Capiz, Philippines.

JUAN DELA CRUZ

Affiant

SUBSCRIBED AND SWORN TO before me, a Notary Public

commissioned in and for the City of Roxas, Province of Capiz, Philippines, this
_____________________ by the affiant who is personally known to me and who
appeared and signed the foregoing AFFIDAVIT OF LOSS in my presence
within my jurisdiction, and who avowed to the truth of its contents under the
penalty of law.

Doc No.______;
Page No._____;
Book No._____;
Series of 2018.