Republic of the Philippines )

City of CALOOCAN ) S.S.

AFFIDAVIT OF LOSS
I, JOEL PALISOC TOLENTINO, of legal age, Filipino, and a resident of 1970 Rosal
Mariposa Subdivision Mateuna, Tayabas, Quezon, after having been duly sworn to in
accordance with law, hereby deposes and says:

1. I am the same person who is the holder of a Philippine Passport with a U.S. visa
stamp issued by the Department of Foreign Affairs.

2. Sometime this year, I realized that my passport, including the U.S. visa stamp, was
part of my documents. Upon checking my documents again, I discovered that my
passport was missing, and I was unable to locate it despite diligent efforts.

3. The lost passport details are as follows:

a. Passport Number: P1290960B

b. U.S. Visa Stamp Number:

c. Issuing Authority: Department of Foreign Affairs

4. I am executing this Affidavit of Loss to attest to the truth of the foregoing and to
request the appropriate authorities for the necessary actions in light of the loss of
my passport.

5. I am willing to provide any additional information or assistance required by the

concerned authorities to facilitate the resolution of this matter.

6. Despite my immediate efforts to apprehend the perpetrator and report the incident
to the local authorities, its contents remain missing to this day.

7. I further affirm under penalty of perjury under the laws of the Philippines that the
information stated in this affidavit is true and correct to the best of my knowledge
and belief.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ________________ at

______________________ City, Philippines.

_____________________________
JOEL PALISOC TOLENTINO
Affiant

SUBSCRIBED AND SWORN TO before me, a notary public in and for CALOOCAN
City this________________________.

The affiant, whom I identified through the following competent evidence of identity:
Driver’s License: N04-97-404540 issued by Land Transportation Office personally signed
the foregoing instrument before me and vowed under penalty of law to the whole truth of
the contents of said instrument.
Doc. No. __________
Page No. __________
Book No. __________
Series of 2023.