REPUBLIC OF THE PHILIPPINES)

Quezon City, Metro Manila ) S.S.

AFFIDAVIT OF LOSS

I, PHIBE S. TALA, of legal age, Filipino, single and a resident of 035

Katarungan St., Brgy. Commonwealth, Quezon City, after having been duly
sworn in accordance with law, hereby depose and say that:

1. I am a holder of Philippine Passport issued by the Department

of Foreign Affairs with passport number PP0431175;

2. The said Passport was put in a brown envelop and placed in a

cabinet together with other personal documents and papers, in
our house at 035 Katarungan St., Brgy. Commonwealth,
Quezon City;

3. Sometime in the late months of 2010, I tried to look for the

said envelop but the said brown envelop was no longer in the
cabinet;

4. I have exerted all my efforts to look for the said brown envelop
containing my Passport and other documents but my effort
proved futile, thus, they are now considered lost and beyond
recovery;

5. I am executing this affidavit to attest to the truth of the

foregoing facts and for purposes of requesting the agencies
concerned for re-issuance of new Paspport in lieu of the lost
one.

IN WITNESS WHEREOF, I have hereunto set my hand this __________

in Quezon City, Philippines.

PHIBE S. TALA
Affiant
________________
________________
________________

SUBSCRIBED AND SWORN TO before me this __________ at Quezon

City, Metro Manila, Philippines.

Notary Public
Doc. No. ____;
Page No. ____;
Book No. ____;
Series of 2011.