Republic of the Philippines)

City of Dagupan ) s.s.

x-------------------------------x

AFFIDAVIT OF LOSS

I, LEAMER CALACSAN y Estrada, of legal age, Filipino citizen,

married, and a resident of Sitio Calay, Barangay Tuliao, Sta. Barbara, Pangasinan,
after being duly sworn in accordance with law, depose and state that:

1. I was issued on 19 June 2018 by the Department of Foreign Affairs (DFA)

National Capital Region North, a Philippine Passport with serial number
P7577263A.;

2. The said passport was destroyed on or about 29 October 2018 due to the
flood caused by Typhoon Rosita;

3. The damage to the passport issued in my name was inadvertent and

unintentional; and

4. I am executing this Affidavit to declare the factual circumstances as to

how said passport was damaged beyond further use and to support my present
application for a new passport to replace the one that was damaged.

Further Affiant sayeth naught.

IN WITNESS WHEREOF, I have hereunto set my hand this 22nd day of

November 2018 in the City of Dagupan, Philippines.

LEAMER E. CALACSAN
Affiant
___________________
___________________

SUBSCRIBED AND SWORN to before me this 22nd day of November 2018

in the City of Dagupan, Philippines.

Administering Officer