Republic of the Philippines)

City of Surigao ) S.S.

AFFIDAVIT OF LOSS

I, ELLEN A. ADARNA, of Legal Age, Filipino, Married, born on with

residential address at 316 Palin St., Block 27, Lot 77, Ai- Ai, General Tinio,
GMA, Cavite, subscribing under oath, hereby depose and state:

1. That I am the holder of a valid Philippine Passport issued by the

Department of Foreign Affairs;

2. That last December 23, 2012, I placed the aforesaid passport

inside my bag while I am at the Central, Commonwealth, Quezon City;

3. That when I looked for the passport inside my bag, I could no

longer locate it;

4. That my said passport could not be found notwithstanding diligent

efforts to locate the same and is now considered lost for all legal intents
and purposes;

5. That I certify this oath to report the loss of my Philippine Passport

issued by the Department of Foreign to avoid the said missing passport
from being used for illegal purposes by other persons;

6. That I execute this affidavit to attest to the truth of all the foregoing
facts and for securing a new Philippine passport.

Affiant further says none.

ELLEN A. ADARNA
Affiant

BEFORE ME, appears the person of ELLEN A. ADARNA presenting

the above Affidavit, who is personally known to me or identified by me
through competent evidence of identity as defined by the Notarial Rules as
the person who signs the document and in my presence taken an oath or
affirmation before me as to such document.

WITNESS MY HAND AND SEAL this 8th day of January, 2014 in

Imus City, Cavite

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 2018.