Republic of the Philippines)

City of Taguig ) S.S.

AFFIDAVIT OF LOSS

I, ELAINE MIRANDA BAYAUA, of legal age, Filipino Citizen, with

residence and postal address at 143 Tanza High-Way, Tuguegarao City,
Cagayan Valley, after having duly sworn to in accordance with law do hereby
depose and state:

That I am a holder and owner of a Philippine Passport, issued by the

Department of Foreign Affairs (DFA);

That sometime on September 2013, at around 11 o’clock in the evening,

while withdrawing some cash at the ATM Machine located in Malate, Manila,
three unidentified men at a knife point forcibly took my cellphone and pouch,
containing the aforesaid Philippine Passport and other important documents and
papers;

That I exerted all efforts to locate or find the aforementioned Philippine

Passport, but proved futile and meaningless whatsoever;

That I am executing this AFFIDAVIT to attest to the truth and veracity of

the above statements for all LEGAL INTENTS and PURPOSES it may serve
best.

IN WITNESS HEREOF, I have hereunto signed my name this 20 th day of

December 2017 at Taguig CIty, Metro Manila.

ELAINE MIRANDA BAYAUA

Affiant

SUBSCRIBED & SWORN TO BEFORE ME THIS 20th day of December

2017 at Taguig City, Metro Manila, affiant exhibiting to me her TIN:333-464-633-
000 issued by Bureau of Internal Revenue.

Doc. No. 506.

Page No. 102.
Book No. VIII.
Series of 2017.