REPUBLIC OF THE PHILIPPINES )

CITY OF CEBU ) S.S.

AFFIDAVIT OF LOSS

I, (Insert Name) , of legal age, Filipino, and a resident of

________________________, Philippines, after having been duly sworn to in accordance
with law, do hereby depose and say that:

1. I am ________________________________________ (e.g., “a holder of a

Philippine Passport with Passport No.”);

2. (State the circumstances of the loss);

3. Despite all diligent efforts to find, locate, recover or retrieve the said
__________________, the same could no longer be found or recovered;

4. Said document is now considered lost and irretrievable; and,

5. I am executing this affidavit to attest to the veracity of the foregoing statements, for
replacement of the same and for whatever legal purpose this may serve.

IN WITNESS WHEREOF, I have set my hand this 25th of September 2021 at the City
of Cebu, Philippines.

(NAME OF AFFIANT)
Affiant
ID and ID No. ___________________

SUBSCRIBED AND SWORN to before me this 25th day of September at the City of
Cebu, Philippines and affiant exhibiting to me her competent evidence of identity indicated
above.

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 2021.