Republic of the Philippines )

City of Baguio )S.S.

AFFIDAVIT OF LOSS

I, _________, of legal age, widow, Filipino and a resident of

___________ after having been duly sworn according to law,
depose and state:

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

Department of Foreign Affairs;

2. That I lost the said Passport in our home in San Isidro, San
Nicolas, Pangasinan;

3. That the said Passport was lost because it was misplaced

among our personal effects and documents for a lapse of
30 years or so since it was last seen;

4. That I am executing this Affidavit to inform the Department

of Foreign Affairs and other issuing authority about the said
loss and to request for the issuance of new Philippine
Passport; and

5. That I attest to the truth of the foregoing facts.

FURTHER AFFIANT SAYETH NONE.

IN WITNESS WHEREOF, I have hereunto set my hand this 9th

of July 2019 in Baguio City, Philippines.

___________
Affiant

SUBSCRIBED and SWORN TO before me this 9th of July 2019 in

Baguio City, affiant exhibiting to me her Senior Citizen ID issued on April
24, 2015, issued by Office of the Senior Citizen Affairs-San Nicolas bearing
the number 15-286, Pangasinan with picture, as proof of her identity.

Doc. No.: 45
Page No.: 9
Book No.: II
Series of 2019