REPUBLIC OF THE PHILIPPINES)

CITY OF MEYCAUAYA, BULACAN ) S.S.

AFFIDAVIT OF LOSS

I, _____________________, Filipino, of legal age, married and a resident

of No. ________________________________, after being duly sworn to in
accordance with law, hereby depose and state:

1. That I am the holder of Passport No. _________________ issued on

_________________________ at Department of Foreign Affairs Manila;

2. That sometime in _______________________, I misplaced the said

Passport and despite diligent efforts exerted to locate the same, I could not
remember exactly where I placed/left it, thus, considered it lost for all legal
purposes;

3. As such, I am executing this Affidavit of Loss to attest to the truth

of the foregoing and to support my application for the issuance of a new
Passport, in lieu of the one that I lost.

IN WITNESS WHEREOF, I have hereunto set my hand this ____day of

_______________ at ____________________________, Philippines.

__________________________
Affiant

SUBSCRIBED AND SWORN to before me this ____________ day of

______________, affiant satisfactorily proven to me her identity through her
______________________, that she is the same person who personally signed
before me the foregoing affidavit and acknowledged that she executed the
same.

Doc No. : ____;

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