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Republic of the Philippines )

) S.S.

I, PAULINE FERNANDO VIVAR, of legal age, Filipino, single, and a resident of
720 Tramo St. Manuyo 1, Las Piñas City, after having been duly sworn to in accordance
with law, hereby depose and state that:

1. I have been duly issued by the Department of Foreign

Affairs (DFA) a Philippine Passport sometime on the year 2015.

2. Around September 2018, our house was hit by typhoon. As

a result thereof, all my papers and official documents were damaged by
flood including my said passport.

3. Corollary, I could no longer recover the said passport.

Hence, I have the reason to believe that it is now truly lost and beyond

4. I am executing this Affidavit to attest to the truth of the

foregoing facts as well as to request from DFA the issuance of a new
passport in my favor and for whatever legal purpose(s) it may serve.


IN WITNESS WHEREOF, I have hereunto set my hand and affixed my signature

this ___ day _________ of __________ 2019.

Pauline Fernando Vivar


SUBSCRIBED AND SWORN to before me this __ day of ____________ 2019,

affiant exhibited to me her Social Security System ID with Number 3478624756.

Until December 31, 20___

Doc. No.______;
Page No.______;
Book No.______;
Series of 2019.