AFFIDAVIT OF LOSS OF PASSPORT

The undersigned, Filipino citizen, married, presently residing at San Pablo Village, Rosary
Heights 11, Cotabato City after having duly sworn to in accordance with law, hereby deposes
and says:

That the undersigned was issued Philippine Passport No. XX0634279 by the Department
of Foreign Affairs in Manila/Consular Extension Office/Philippine Embassy/Consulate in Davao
City on February 29, 2008;

That said passport was lost on June 8, 2018 under the following
circumstances:
When I arrived home from office, I discovered that the said passport was not in my
cabinet where I used to place all of my important personal documents.

That the undersigned exerted all efforts possible to locate said passport to no avail;

That the undersigned fully understands that the said passport is automatically deemed
cancelled upon declaration of loss, and that if found, it can no longer be used;

That undersigned is executing this affidavit of loss in connection with his/her present
application for a new passport;

That further Affiant/s sayeth none.

IN WITNESS WHEREOF, undersigned hereby affixes his/her signature this

9th day of October 2018 in Cotabato City, Philippines.

_____________________________
Affiant

SUBSCRIBED AND SWORN to before me this 9th day of October 2018 in Cotabato
City, Philippines. The Affiant having exhibited to me his/her Identification card No.
DARRO-17-030 issued at Department of Agrarian Reform - ARMM.

_________________________________
Administering Officer/Notary Public