Republic of the Philippines )

City of Tacloban ) S.S.

AFFIDAVIT OF LOSS
I, _____________________ of legal age, single, Filipino, and a resident of
Brgy. _________________________, after having been sworn to in accordance
with law, hereby depose and state: THAT -

1. That I am a Filipino citizen and holder of a Philippine Passport

issued by the Philippine Embassy in ________________ with Passport No.
_____________ issued on ___________________;

2. That the said passport got misplaced when

______________________________;

3. That last _________________, I exerted diligent efforts in trying to

locate the said DFA Philippine Passport by looking for it in the said suit case,
however, the same was not contained therein anymore;

4. In spite of diligent efforts to locate the same in all corners of my

room and even in the entirety of our home, the same could not be found;

5. Hence, I now conclude that the same is now lost and is beyond
recovery;

6. That I am executing this Affidavit for the purpose of explaining the

fact of loss of my Philippine Passport for the purpose of its reissuance in my
favor, and for attesting to the truth and veracity of the foregoing statements and
for whatever legal purpose this may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this

______________________ in ___________________.

________________________________
Affiant

SUBSCRIBED AND SWORN to before me this ______________________

in Tacloban City, Philippines by the affiant who presented to me her
______________________ issued on _______________________ as competent
evidence of her identity, known to me to be the same person who executed this
foregoing affidavit.

Doc. No. _____;

Page No. _____ ;
Book No. _____;
Series of 2019.