REPUBLIC OF THE PHILIPPINES )

City of Dumaguete)S.S.

AFFIDAVIT OF LOSS

I, LADY FABRIENNE VILLARIN, Filipino, of legal age, residing at EJ Blanco Drive,

Piapi, Dumaguete City, after having been sworn in accordance with law hereby
depose and state:

1. That I am a holder of a Philippine Passport No. XX1644903, issued on July 21,

2008;

2. That sometime June of last year, I was looking for the Philippine Passport but to
my surprise, said certificate could not found;

4. All my efforts to recover said passport was to no avail;

5. That I am executing this affidavit for the purpose of affirming the truth of the
foregoing statements and for any legal purpose this may serve.

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

_______________. 20___ at _________________________.

LADY FABRIENNE VILLARIN

Affiant

SUBSCRIBED AND SWORN to before me this ______th day of

______________, 2018. Affiant exhibiting to me his evidence of identity
___________________________.

NOTARY PUBLIC
Doc. No. : ________;
Page No. : ________;
Book No. : ________;
Series of 20_______.