REPUBLIC OF THE PHILIPPINES)

CITY OF MAKATI

) S.S.

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

AFFIDAVIT OF LOSS

I,

___________________, of

legal

age,

Filipino,

single

and

resident

of

_______________________________, after having been duly sworn to in accordance with law, depose and
state THAT:

1. On January 12, 2010, I was issued a Philippine Passport by the Department of Affairs in Manila;

2. Recently, I had tried to look for the said passport but the same could not be found;

3. Despite diligent search and efforts to locate the said passport, I could not find the same such that I believe that
it is now lost beyond recovery;

4. As such, I am executing this affidavit to attest to the foregoing facts and to support the application for the
issuance of a new one in lieu of the one which was lost.

IN WITNESS WHEREOF, I have hereunto set my hand this ___________________ in Makati City,
Metro Manila, Philippines.

____________________
Affiant
GSIS ID No. _____________

SUBCRIBED

AND

SWORN

TO before

me

this ___________________ in

_________________, Philippines, affiant exhibiting to me his valid proof of identification.

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 2013.