REPUBLIC OF THE PHILIPPINES )

MEYCAUAYAN, ) SS.

AFFIDAVIT OF LOSS

I, Raymond Bernal Uribe, Filipino, of legal age, single, and a resident of Marilao,
Bulacan after having been duly sworn in accordance with law, hereby depose and say:

1. That I am a holder of a Philippine Passport issued by the Department of

Foreign Affairs;

2. That I used to put said Passport together with other personal documents in my
wallet;

3. That unfortunately I misplaced the said wallet sometime in March 2018;

4. That despite diligent search and efforts to locate said wallet I could not find it,
and is now lost beyond recovery;

5 That I am executing this affidavit to attest to the truth of the foregoing facts and
to request for a replacement of the said passport.

IN WITNESS WHEREOF, I have hereunto affixed my signature this

___________ at ____________________, Philippines.

___________________________
AFFIANT

Before me a Notary Public for and in Meycauayan, personally appeared

_______________________________ on ___________, whom I have identified
through her ______________________________________.

Notary Public
Doc. No. ……..;
Page No. …….;
Book No. …….;
Series of 2018.