REPUBLIC OF THE PHILIPPINES )

CITY OF ILOILO ) S.S.

x-----------------------------------------------------x


AFFIDAVIT OF LOSS

I, JOVEN T. MANA-AY, of legal age, Filipino and a resident of Purok IV, Pavia,
Iloilo, after having been duly sworn to in accordance with law, do hereby depose and say:

That I was issued/ a holder of a Philippine Passport by the Department of Foreign Affairs.
The details of which I could no longer recall;

That said Philippine Passport was lost sometime on the last week of January, 2014;

The said loss was duly recorded in the police blotter of Pavia Police Station on May 31,
2014, a copy of said Certification is hereby attached as Annex A;

That the same could no longer be located despite diligent efforts and is now considered
lost and beyond recovery;

That I am executing this affidavit to attest to the truth of the foregoing statements and to
request for the issuance of a new Philippine Passport in lieu of the one which was lost.

IN WITNESS WHEREOF, I have hereunto set my hand this 3
rd
day of June, 2014 at
Iloilo City, Philippines.


JOVEN T. MANA-AY
Affiant



SUBSCRIBED AND SWORN to before me this 3
rd
day of June, 2014 at Iloilo City,
Philippines, affiant personally exhibiting to me his competent evidence of identity which is:
___________________________________________________.





Doc No. ______;
Page No.______;
Book No. _____;
Series of 2014.