REPUBLIC OF THE PHILIPPINES )

PROVINCE OF ____________ )
CITY OF ________ )

SWORN AFFIDAVIT OF LOSS

OF MR. [NAME]

I, [NAME], Filipino, married, of legal age, and a resident of

[ADDRESS], after having been duly sworn in accordance with law, hereby
depose and state that:

1. I was previously the holder and owner of a Philippine Passport

(“Passport”), duly issued in my name and favor by the
Department of Foreign Affairs–Office of the Consular Affairs
(“DFA-OCA”), approximately twenty (20) years ago.

2. During such time that I was in possession of said Passport, I used

to store and safekeep the same in our previous home located in
[ADDRESS].

3. Sometime around 2024, and years after moving into our new
residence in [ADDRESS], however, I discovered that said Passport
was missing and/or nowhere to be found.

4. My attempt to locate said Passport, despite exerting diligent

efforts, proved utterly futile.

5. In view of the foregoing, I now sincerely desire and respectfully

request DFA-OCA [BRANCH], to grant me permission in
applying for the issuance of a new Passport under my name and
in my favor, and in the event of a successful processing of said
application, be issued a new Passport in lieu of the lost one.

6. I am executing this affidavit to comply with the requirements of

DFA-OCA [BRANCH], and for the purpose of applying for the
issuance of a new Passport under my name and in my favor.

7. I hereby attest to the truthfulness of the foregoing statements.

8. This affidavit is, likewise, being executed for whatever legal

purpose/s this may serve, in addition to those above-stated.
 IN WITNESS WHEREOF, I have affixed my signature this
______________________ in [PLACE].

[NAME]
Affiant

SUBSCRIBED AND SWORN TO, before me, a notary public, on

__________________, in [PLACE], affiant personally appeared before me,
exhibiting his _________________ with _____________________ expiring
on/valid until _______________________.

Doc. No. ___;

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