AFFIDAVIT OF LOSS

I, the undersigned, a Filipino citizen, of legal age, presently residing at

________________________________________________________________, after having
been duly sworn to in accordance with the law, do hereby depose and say:

1. That I lost my Philippine Passport numbered ____________,

issued at DFA Manila on _______________;

2. That sometime in ____________, I noticed that said passport was

missing;

3. That to my knowledge, said passport was lost when I relocated to

another residence sometime in ________________;

3. That despite the exertion of diligent effort in locating the said lost
passport, the same could no longer be found;

4. That I am executing this affidavit of loss in connection with my present

application for a new passport, and;

5. That I attest to the veracity of the foregoing information.

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

___________ in the City of __________.

Affiant

REPUBLIC OF THE PHILIPPINES)

) S.S.

SUBSCRIBED AND SWORN to before me, this ____ day of _________, by the
affiant who exhibited to me his ID No. ______________ issued at ______________,
Philippines on _____________.

Notary Public

Doc. No. ______;

Page No. ______;
Book No. ______;
Series of 20___;