REPUBLIC OF THE PHILIPPINES )

Zamboanga del Sur ) S.S.

Pagadian City

AFFIDAVIT OF LOSS OF PASSPORT

I, ______, Filipino, of legal age, single/married, and with residence at
______, Philippines, after being duly sworn to in accordance with law, hereby
depose and state:

1. That I was issued Philippine Passport No. __ by the Department of Foreign

Affairs ___ on ___;

2. That said passport was lost on ____ when ____

3. That despite diligent search and efforts to locate said passport, I could
not find the same such that I now believe that it is now lost beyond
recovery;

4. That I fully understand that the said passport shall automatically be

deemed cancelled upon declaration of loss, and that if found, it can no
longer be used;

As such, I am executing this affidavit to attest to the truth of the

foregoing and to support my application for the issuance of a new passport.

IN WITNESS WHEREOF, I have hereunto set my hand this

______________________ at Pagadian City, Zamboanga del Sur, Philippines.

________________
Affiant

SUBSCRIBED and SWORN TO before me by affiant, on the date and at

the place indicated above.

WITNESS MY HAND AND SEAL.

Doc. No. _____;

ATTY. GIL MAE N. HUELAR-DIN
Page No._____; Notary Public
Book No._____; Pagadian City & Zamboanga del Sur
Until December 31, 2020
Series of 2020 Roll of Attorneys No. 67520
PTR No. 3204245; 1/8/2020; Zam. del Sur
IBP No. 113837; 1/15/2020/ IBP-ZDS Chapter
MCLE Compliance No. VI-0002979