AFFIDAVIT OF LOSS

REPUBLIC OF THE PHILIPPINES )

_________________________ ) SS.

I, Vanessa G. Javier, Filipino, of legal age, single, and a resident of 19-A ROTC St.,
Rosario, Pasig City, after having been duly sworn in accordance with law, hereby
depose and say:
1. That I am a holder of a Passport with No. XX2744130, issued on 01/07/2009,
issued at Department of Foreign Affairs in Manila;
2. That sometime on June 18, 2013 I discovered that it was lost and nowhere to
find;
4. That diligent search of said document proved futile and unavailing;
5. That I am executing this affidavit to attest to the truth of the foregoing facts
and to request for a replacement of said passport.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ____day of

____________ 20___ at ____________, Philippines.

VANESSA G. JAVIER
Affiant

SUBSCRIBED AND SWORN TO before me, a notary public in and for

_____________________ this ____ day of ____________ 20___. The affiant, whom I
identified personally signed the foregoing instrument before me and avowed under
penalty of law to the whole truth of the contents of said instrument.

Notary Public

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Page No. .;
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Series of 2014.