AFFIDAVIT OF LOSS

I, ZENY CULLA BAHALA, Filipino citizen, of legal age and presently residing at BLK 14 LOT 15

EZEKIEL ST. PHASE 2 SAMPAGUITA WEST SUBDIVISION, SAMPAGUITA LIPA CITY, BATANGAS, after

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

1. That I am holder of Philippine Passport No. EB1033926 issued on September 27, 2010

2. That sometime around May 1, 2021, I noted that the said passport was missing.

3. That to my knowledge, I accidentally left and lost it when we were relocating from our old

house to our new house.

4. That I took grate pains to look for the said passport but to no avail.

5. That I am making this affidavit for the purpose of providing the truth and veracity of the
above facts to the office concerned.

IN WITNESS WHEREOF, I have here unto set my hand this_________________ at Lipa City.

ZENY CULLA BAHALA

Affiant

SUBSCRIBED AND SWORN, to before me, this________________ at Lipa City.

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