REPUBLIC OF THE PHILIPPINES )

CEBU CITY )S.S.

AFFIDAVIT OF LOSS

I, MARITES TEMPLE LAMOSAO, of legal age, married, Filipino

and a resident of Lawaan Alcantara Cebu, after being sworn to in
accordance with law, hereby depose and say, THAT:

1. I am a holder of a Philippine Passport with Passport Number

EP7356912A;

2. I have validly acquired the same after applying for its issuance on
_____________________;

3. On _____________________, the said Passport which was in my physical

possession was lost after attending mass and doing some errands
near and/or around downtown Cebu.

4. After discovering its loss, I went back to the places I visited that
date in the hopes of recovering the said document. However, such
efforts were to no avail.

5. Consequently, my Diploma was considered lost or stolen and

beyond recovery;

6. The purpose of this Affidavit of Loss is for securing a replacement

for the lost Philippines Passport in the Department of Foreign
Affairs;

7. I am executing this affidavit for the aforesaid purpose/s as well as

for attesting to the truth of the statements herein declared, subject
to the rules on perjury.

AFFIANT FURTHER SAYETH NAUGHT.

MARITES TEMPLE LAMOSAO

Affiant
ID No. ______________

SUBSCRIBED AND SWORN to before me this _________________at Cebu

City, Philippines. Affiant exhibited to me her competent proof of identity
as above mentioned.