REPUBLIC OF THE PHILIPPINES )

Municipality of Paniqui ) S.S

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AFFIDAVIT OF LOSS

I, RICARDO VINEGAS, of legal age, Filipino, married and a resident of Purok 5,

Dapdap, Paniqui Tarlac after having been duly sworn to in accordance with law, hereby
depos and state:

1. That I am the lawful holder of Philippine Passport issued in Riyadh;

2. That sometime on January 2018, said passport was lost inside my bag, I could
not locate the same and I discovered that it was lost/missing. Then, I tried to
look for it and other belongings but I did not find the same;
3. That I diligently exerted efforts to locate the said passport, but in spite of
diligent search, it could not be found, hence, the same is deemed lost and at
a point beyond recovery;
4. That the said passport has not been encumbered, sold, pledged, assigned,
alienated, transferred, donated, or given as collateral for any debt or obligation
to or in favor of any person or entity;
5. That I understand that my declaration of the abovementioned passport as lost
shall be construed as satisfactory proof that the passport was lost, In
compliance with section 15 or RA 8239 or the Philippine Passport Act of 1996;
6. That I further understand that said passport will be immediately deemed
cancelled and may no longer be used for travel or other purposes.
7. That I am executing is affidavit to attest to the veracity of the foregoing facts
and for whatever legal purpose it may serve under law.

IN WITNESS WHEREOF, I have hereunto set my hand this 19th day of November,
2019, in the Municipality of Paniqui, Province of Tarlac, Philippines.

RICARDO VINEGAS
Affiant

SUBSCRIBED AND SWORN to before me this 19th day of November 2019, in the
Municipality of Paniqui, Province of Tarlac, Philippines.
Doc. No. _____;
Page No. _____;
Book No. _____;
Series of 2019.