REPUBLIC OF THE PHILIPPINES )

PROVINCE OF )
MUNICIPALITY ) S.S.
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AFFIDAVIT OF LOSS

I, , of legal age, Filipino, married, and

resident of , after being duly sworn according to
law, hereby depose and state that:

1. I am a holder of a Philippine Passport issued by the Department of

Foreign Affairs (DFA);

2. Sometime on the year 2011, I lost my Philippine Passport as it was

probably stolen, dropped or misplaced;

3. Despite diligent efforts exerted, I could no longer locate, find or recover the
said Philippine Passport, and to the best of my knowledge, the same is truly
lost;

4. The said Philippine Passport has not been confiscated by any officer of the
law or the issuing office or agency due to the violation of any law, statute,
order, rule or regulation; and

6. I am executing this Affidavit to attest to the truth of the foregoing

statements and for the renewal of my Philippine Passport with DFA
.

IN WITNESS WHEREOF, I have hereto affixed my signature this

day of February, 2024 at , Philippines.

Affiant
ID No.

SUBSCRIBED AND SWORN to before me this day of February, 2024 at

, Philippines, affiant exhibited to me his competent
evidence of identity as indicated under his name and signature above.

Doc. No. ______;

Page No. ______;
Book No. ______;
Series of ______.