REPUBLIC OF THE PHILIPPINES)

CITY OF PASAY            ) S.S.

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

AFFIDAVIT OF LOSS

I, EDDYSA TORDESILLAS MILLAN, of legal age, Filipino, single and a

resident of 158 P. Manahan Street, Pasay, after having been duly sworn to in
accordance with law, depose and state THAT:

1. I am a teacher in Bangkok, Thailand;

2. I am a holder of Philippine Passport No. EC5633312 issued on 08

October 2015 at Philippine Embassy in Bangkok, Thailand;

3. Sometime on April 2017, the said Philippine passport was missing;

4. To my knowledge, my Philippine passport was lost when I arrived in

the Philippine airport;

5. Efforts were exerted to locate the said Philippine passport, but despite
of diligent search, it could not be found and the same is now beyond
recovery;

6. The said Philippine passport has not been confiscated by any authorities
of the Philippine government;

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

foregoing and for the purpose of re-application of new Philippine
passport;

IN WITNESS WHEREOF, I have hereunto set my hand

this ___________________ in Pasay City, Metro Manila, Philippines.

EDDYSA TORDESILLAS MILLAN

Affiant

SUBCRIBED AND SWORN TO before me this ___________________ in

_________________, Philippines, affiant exhibiting to me his/her competent
evidence of identity by way of __________________ issued at ______________
on __________________.

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 2017.