Republic of the Philippines )

Province of La Union ) S.S

Municipality of ______________ )

AFFIDAVIT OF LOSS

I, ______________________, of legal age, single, Filipino and a resident of

Lacong, San Gabriel, La Union, Philippines, after having been sworn to in
accordance with law, do hereby depose and state:

1. That I was previously issued a Philippine passport by the Department of

Foreign Affairs, ______________________;

2. That on December 3, 2021, I discovered that the bag where I keep all my
important documents, including the aforementioned passport, was no
longer inside the cabinet in my room;

3. That diligent efforts were exerted to locate the bag but all such endeavors
proved futile and to no avail, hence the same is already deemed lost,
together with all its contents, at a point beyond recovery;

4. That said passport had never been encumbered, sold, pledged, donated,
assigned, transferred or given as a security or collateral to answer for any
debt or obligation in favor of any person, office or entity;

5. That I understand that my declaration of the above-mentioned passport as

lost shall be construed as satisfactory proof that the passport was lost, in
compliance with Section 15 of RA 8239 or Philippine Act 1996;

6. That I further understand that the said passport will be immediately

deemed cancelled and may retrieved, undersigned will immediately
surrender it to the DFA; and

7. That I am executing this affidavit to attest to the veracity of the foregoing

facts and for all legal intents and purposes this may serve best.

IN WITNESS WHEREOF, I have hereunto set my hand this

___________________, at San Gabriel, La Union, Philippines.

_________________________
________________________
Affiant

SUBSCRIBED AND SWORN TO before me this ________________ at San

Gabriel, La Union, Philippines, affiant exhibited to me her ID with details indicated
below her name as proof of her identity.