REPUBLIC OF THE PHILIPPINES )

) S.S.

AFFIDAVIT OF LOSS OF PASSPORT

I, ----, Filipino citizen, of legal age and presently residing at No.

-------------, after having been duly sworn to in accordance with law,
hereby depose and state:
1. That I am a holder of Philippine Passport issued last 2013;

2. That three (3) days ago, said Passport was misplaced and
got lost;

3. That despite diligent search and efforts to locate my

Passport, I could not find the same, such that I now have
reasons to believe that it is now lost and can’t be recovered;

4. That said Passport has not been confiscated by any

government office for any violation;

5. As such, I am executing this Affidavit of Loss to attest to the

truth of the foregoing and to support my application for the
issuance of a new Passport, in lieu of the one that was lost.
IN WITNESS WHEREOF, I have hereunto signed my name
below this _______________ at _______________, Philippines.

------------
Affiant

SUBSCRIBED AND SWORN to before me this _______________

at _______________, Philippines, affiant exhibiting to me her ---------.

Doc. No.: ___;

Page No.: ___;
Book No.: ___;
Series of 2019.