REPUBLIC OF THE PHILIPPINES )

MUNICIPALITY OF DUMALINAO ) S.S

AFFIDAVIT OF LOSS

I, MICHELLE A. SABELLA, of legal age, married and residing at Barangay

Tickwas, Purok Sikatuna, Dumalinao, Zamboanga del Sur, after having been
duly sworn to according to law hereby depose and state:

1. That I am the owner of a Philippine Passport bearing passport number

P6112438B;

2. That on October 11, 2021, I was carrying the passport inside my wallet
while riding a motor cycle. However, I did not notice it must have slipped
from my bag because after reaching Pagadian City, I hurriedly tried to
search for it but I was shocked as it was not there anymore;

3. That after diligent efforts to search and locate the same, it was nowhere to
be found anymore;

4. That I am executing this affidavit in order to attest to the truth of the

foregoing circumstances and for the purpose of securing another passport.

IN WITNESS WHEREOF, I have hereunto set my hand this __day of

January, 2024 at the Municipality of Dumalinao.

MICHELLE A. SABELLA
Affiant

SUBSCRIBED AND SWORN to before me this __ day of ___________ 2024,

affiant exhibited to me her Philhealth ID bearing number 14-025234185-0
as a competent proof of her Identity:

Doc. No. __________;

Page No. __________;
Book No. __________;
Series of 2024.