Republic of the Philippines) of

Batangas )s.s.
X X

AFFIDAVIT OF LOSS

I, ROMA JOY M. LANDICHO Filipino, single, of legal age, resident of Barangay

Santiago Malvar, Batangas, Philippines, after having been sworn by law hereby depose
and state that:

1. I am the owner of a Passport with the number P3739564A issued by the Department of
Foreign Affairs -Manila;

2. Sometime around 5:30 in the afternoon on April 15, 2024, in Santiago, Malvar Batangas,
I lost the above Passport under the following circumstances:

3. despite diligent efforts exerted, I could not expect that the said passport was an-
intentionally lost in my bag and I don’t expect that it will lost, and to the best of my
knowledge, the same is truly lost;

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

5. I fully understand that the moment the passport is declared lost or stolen, it is
automatically deemed canceled and that if found, it can no longer be used to avoid
complications with immigration authorities;

6. If the lost passport should hereafter be found or located, I undertake to forward or

surrender the same to the Department of Foreign Affairs for appropriate disposal;

7. I am executing this affidavit to attest to the truth of the foregoing and to request the
issuance of a new passport to replace the one that was lost.

IN WITNESS WHEREOF, I have hereunto set my hand this 28th of June, 2024, in Malvar,
Batangas, Philippines.

ROMA JOY M. LANDICHO

Affiant
Issued ID: Tin ID
ID NO. 640-090-017-00000

SUBSCRIBED AND SWORN to before me on this 28th day of June 2024, in Malvar,
Batangas Philippines.

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