AFFIDAVIT OF LOSS

I, ____________, of legal age and a resident of

_____________________, after being sworn to in accordance with the law,
do hereby depose and say:

1. That sometime around August/September 2014 I was deported back

to the Philippines from the ____________.

2. That travel documents were issued by the Immigration Authorities of

_________ so that I could travel back to the Philippines since my
passport was confiscated when I was apprehended by the former.

3. That the said documents were in my possession from the time of

issuance but sometime on ____________ or thereabout, the same
were lost and notwithstanding diligent efforts, the same cannot be
located or recovered.

4. That I am executing this affidavit to attest the truth and for whatever
legal purpose it may serve.

________________
_______________
Affiant

SUBSCRIDED AND SWORN to before me this 5th of January 2015 in

Makati City, affiant exhibiting his Driver’s License No. ______ issued
on ________ at ________.

Doc. No. ____:

Page No. ____:
Book No. ____:
Series of