REPUBLIC OF THE PHILIPPINES)

CITY OF MUNTINLUPA) S.S.

AFFIDAVIT OF LOSS OF PASSPORT

I, IRENE IRENE, of legal age, a citizen of both the Philippines and the United States of
America, and with residential address in Makati City, after having duly sworn in accordance with law,
do hereby depose and state that:

1. I was once issued a Philippine Passport by the Department of Foreign Affairs

(DFA) of the Republic of the Philippines, the particulars of which I could no longer recall.
Thereafter, around twenty-seven (27) years ago, I lost the said Philippine Passport; and after I
exhausted careful and diligent efforts to search and look for the same, I then deemed that the said
Philippine Passport was truly and irretrievably lost, and was then beyond recovery.

2. I am executing this affidavit to attest to the truth and veracity of the foregoing, as a
requisite for my application for another Philippine Passport before the DFA, and for whatever other
legal purposes the same may serve.

Affiant further sayeth naught.

IN WITNESS WHEREOF, I have hereunto set my hand this 1st day of October 2018, in
the City of Muntinlupa, Metro Manila.

IRENE IRENE
Affiant

SUBSCRIBED AND SWORN TO before me, this 1st day of October 2018, the affiant
Irene Irene exhibiting to me her competent evidence of identity in the form of __________ with
number _________________.

Doc. No. ______;

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