REPUBLIC OF THE PHILIPPINES)

CITY OF PASIG )S.S.

AFFIDAVIT OF LOSS

I, PRINCESS STEPHANIE M. BARUC , of legal age, Filipino, single with

residence address at Block 36 Lot 46, Ph.2 A2, Kaunlaran, Village Navotas City,
after having been duly sworn under oath, hereby depose and say:

1. That I am a holder of Passport with Passport No.EB 4751147 issued on

February 20, 2012 Expiration date on February 19, 2017 issued by the
Department of Foreign Affair (DFA);

2. That said Passport was missing at the time when I am about to use the
same, presumably it was misplaced by unknown circumstances and
despite my diligent efforts exerted to locate the same, I could no longer
find it, hence considered permanently lost;

3. That I am executing this affidavit to attest to the truth of the foregoing

allegations and for whatever purposes this may serve.

IN WITNESS HEREOF, I have hereunto set my hand this

________________at Pasig City.

PRINCESS STEPHANIE M. BARUC

Affiant

SUBSCRIBED AND SWORN to before me this ___________________,

Pasig City.

Doc. No.
Page No.
Book No.
Series of 2022.