REPUBLIC OF THE PHILIPPINES )

CITY OF DAVAO ) SS.

AFFIDAVIT OF LOSS

I, _______________________, Filipino, of legal age, and a resident of Davao City,

Philippines, after having been duly sworn in accordance with law, hereby depose and
state that:

1) Sometime in July 2016, I applied for a Passport at Department of Foreign

Affairs in SM City Davao, Ecoland, Davao City;

2) After I paid the fees for my application, the cashier issued an official
receipt, and thereafter, I placed the same inside my wallet;

3) On July 15, 2016, when I was at Abreeza Ayala Mall in J.P. Laurel Ave.,
Davao City, I noticed that my wallet, where the aforementioned official receipt was
placed, was no longer in my possession;

4) I tried to locate the said wallet, but I was not able to find the same;

5) Despite diligent efforts exerted, I could no longer locate, find or recover

the abovementioned official receipt, and to the best of my knowledge, the same is truly
lost;

6) I am executing this affidavit to attest to the truth of the foregoing facts.

IN WITNESS WHEREOF, I have hereunto set my hand this ___________ 2016 in

Davao City, Philippines.

______________________________
Affiant

SUBSCRIBED AND SWORN TO before me this ______________ 2016 in Davao

City, Philippines, affiant exhibiting to me his Driver’s License No. __________________.

Doc. No. _______

Page No. _______
Book No. _______
Series of 2016.