REPUBLIC OF THE PHILIPPINES)

______________________________) S.S.

AFFIDAVIT OF LOSS
PHILIPPINE PASSPORT
I, __________________, Filipino, of legal age, single, and a resident
________________________________, Philippines, after having been duly sworn in
accordance with law, hereby depose and say:
1. That I am the lawful holder of Philippine Passport No. ___________ issued by the
Department of Foreign Affairs (DFA) Consular Office Baguio City;

2. That sometime in __________, I lost said passport;

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, and 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 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 the DFA;
and

7. That I am executing this affidavit to attest to the foregoing facts and for any legal
purpose it may serve.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ____________ at

_____________________________.

____________________________________
Affiant

SUBSCRIBED AND SWORN to before me this _______________, in _____________

exhibiting his/her ______________________________. I certify that I personally examined the
affiant and that she voluntarily executed the foregoing affidavit and understood the contents
thereof.
Doc. No.: _____;
Page No.:_____;

Book No.:_____;

Series of 2020