REPUBLIC OF THE PHILIPPINES )

PROVINCE OF PANGASINAN ) S.S.

CITY OF SAN CARLOS )

AFFIDAVIT OF LOSS

I, Mary Joan S. Sabangan, Filipino, of legal age, and residing at #499 Brgy. Cobol, San
Carlos City, Pangasinan, after having been sworn according to law, hereby depose and state
that:

1. I am the owner of a Philippine passport, the number of which I could no longer recall,
issued by the Department of Foreign Affairs, Calasiao, Pangasinan.

2. On or about 16 May 2019, I discovered the loss of the said passport under the following
circumstances:

I keep my passport in the same place, particularly in an envelope in a drawer in my

room. When I needed my passport to be used for our flight booking to Hongkong, I
discovered that my passport was not in my envelope anymore.

3. Despite diligent efforts, I could not find nor locate the same and I believe that it is truly
lost.

4. I am executing this affidavit for whatever legal purpose it may serve and to request for a
replacement of said passport from the Department of Foreign Affairs.

Signed on the date and the place indicated below.

__________________________
Mary Joan S. Sabangan
Affiant

SUBSCRIBED AND SWORN to before me this 13 th day of June 2019 at SAN CARLOS
CITY, PANGASINAN, affiant Mary Joan S. Sabangan personally appeared before me and
exhibited to me PRC ID no. 1584988 and is valid until 25 November 2020.

Doc. No.: ___________

Page No.: ___________
Book No.: ___________
Series of ____________