REPUBLIC OF THE PHILIPPINES )

PROVINCE OF XXX ) S.S.

CITY OF XXX )

AFFIDAVIT OF LOSS
I, ___________________, of legal age, Filipino, married, and residing at
__________________________, after having been duly sworn to in accordance with law, depose
and state:

1. That I am a lawful holder of Philippine Passport bearing No. ___________________

issued by the Department of Foreign Affairs on _______________ and valid until
__________________;
2. That sometime in _____________, said passport was misplaced and nowhere to be
found;
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 of 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. As such, in case the said
passport is found or retrieved, undersigned will immediately surrender it to DFA; and

7. That I am executing this affidavit to attest to the veracity of the foregoing facts and
for whatever legal purpose it may serve under the law.

IN WITNESS WHEREOF, I have hereunto set my hand this _________________ in

__________________, Philippines.

_________________
Affiant