Republic of the Philippines )

City of Cagayan de Oro ) ss.

AFFIDAVIT OF LOSS PASSSPORT

I, PRIMA DONNA B. BELTRAN, of legal age, Filipino, and a resident of

Poblacion, Laguindingan, Misamis Oriental, after having been duly sworn in
accordance with law, hereby depose and state:

That sometime in 2013, I was issued a Philippine Passport by the

Department of Foreign Affairs in Cagayan de Oro City;

That recently I had tried to look for the said passport but the same could
not be found;

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

That I am executing this Affidavit of Loss to attest to the truth of the

foregoing and to support the application for the issuance of new one in lieu of
the one which was lost.

IN WITNESS WHEREOF, I have hereunto set my hand this 9th day of July
Cagayan de Oro City, Philippines.

PRIMA DONNA B. BELTRAN

Affiant
VIN: 4318-0017A-L3185PBB20002-6

SUBSCRIBED AND SWORN to before me this 9th day of July, 2018 at

Cagayan de Oro City, Philippines.

Doc. No. __499_;

Page No. __100_;
Book No. ____I_;
Series of 2018