REPUBLIC OF THE PHILIPPINES)

Province of Agusan del Sur ) S.S.

Municipality of Prosperidad )
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AFFIDAVIT OF LOSS

I, ETHEL SADAY NABUTAS Filipino, of legal age, and a resident of P-1,

Cabantao, Rosario, Agusan del Sur, after having been sworn in accordance with law, hereby
depose and state THAT:

1. That I am the same person executing this Affidavit;

2. I am a holder of a Philippines Passport and was issued by Department of Foreign

Affairs with Passport ID as proof thereof

3. Sometime in October 30, 2019, while I was riding a Public Utility Bus traversing to Davao City,
I unconsciously dropped my yellow wallet containing the such Passport ID;

4. I exercised due diligence in locating the said Passport ID and have reported its loss to Rosario
Municipal Police Station;

5. My efforts to locate my Passport ID have failed since until now the same has not been found,
leaving me with no other recourse but to request and process for the issuance of a replacement
thereof, for which purpose this affidavit is executed; and

6. I attest to the truth of the foregoing statements.

IN WITNESS WHEREOF, I hereunto affix my signature this 13th day of June 2020 at Patin-ay,
Prosperidad, Agusan del Sur, Philippines.
 

ETHEL SADAY NABUTAS

Affiant
TIN ID No. 758-552-311-000

SUBSCRIBED AND SWORN to before me, this 13th day of June 2020 at Patin-ay,
Prosperidad, Agusan del Sur, Philippines.