REPUBLIC OF THE PHILIPPINES )

CITY OF SAN JOSE DEL MONTE )S.S.

PROVINCE OF BULACAN )
x-------------------------------------------x

AFFIDAVIT OF LOSS

I, MA. JOCEL MARTOS, of legal age, Filipino, with residence

address at
_________________________________________________________,
City of San Jose del Monte, Bulacan, after having been duly sworn in
accordance with law hereby dispose and state, to wit:

1. I am the holder of Passport Claiming Stub issued by

____________’

2. That, upon arriving home I discovered that the said Passport

Claiming Stub is missing.

3. That, I exerted my best effort to find and locate the said Passport
Claiming Stub where I placed the above-stated missing but my
efforts proved futile and in vain;

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

veracity of the foregoing facts and for whatever legal intent and
purposes it is deemed proper;

IN WITNESS WHEREOF, I hereby affix my signature this ___ day of

November 2018 at the City of San Jose del Monte, Bulacan.

MA. JOCEL MARTOS

Affiant

SUBSCRIBED AND SWORN to before me this 3rd day of April 2018

at the City of San Jose del Monte, Bulacan. Affiant exhibiting to me his
_________________________________ at _______________, Bulacan.

NOTARY PUBLIC

Doc. No. ____:

Page No. ____;
Book No. ____;
SERIES OF 2018