Republic of the Philippines )

Province of Bohol )s.s.

Municipality of Ubay )

AFFIDAVIT OF LOSS

I, X, Filipino, of legal age, single and resident of a, Alicia, Bohol, after

having been duly sworn to in accordance with law, do hereby depose and state:

1. That a Philippine Passport No. 41224 was issued under my name by the
Department of Foreign Affair Manila on April 21, 2017;
2. That said passport was lost on
3. That despite diligent efforts to locate said passport, I could not find the same
such that I now believe that it is now lost beyond recovery;
4. That I fully understand that the said passport shall automatically be deemed
canceled upon declaration of loss, and that if found it can be no longer be
used;
5. As such, I am executing this affidavit to attest to the truthfulness of the
foregoing facts and to support my application for the issuance of new
passport.

IN WITNESS WHEREOF, I have hereunto set my hand this 16 th day of

February 2023 at Ubay, Bohol.

X
Affiant

SUBSCRIBED AND SWORN to before me this 16th day of February 2023

at Ubay, Bohol.

WITNESS MY HAND AND SEAL.

Doc. No. ___

Page No.___
Book No. ___
Series of 2023.