Republic of the Philippines)

City of Masbate )S.S

AFFIDAVIT OF LOSS
I, __________________, of legal age, Filipino citizen, married, and a resident of
Pilar, Sorsogon, after having been sworn to in accordance with law, hereby depose and
say;
1.That last September 2020, I was issued by Department of Foreign Affairs a
Claim Stub and Receipt for the renewal of my passport;
2.That recently, I tried to look for the Claim Stub and Receipt but the same could
no be found;
3.That despite diligent search and efforts to locate I could not found the same
such that now I believe it is lost beyod recovery;
IN WITNESS WHEREOF, I have hereunto affixed my signature this
September 1, 2020, at Legazpi City, Philippines.

__________________
Affiant

SUBSCRIBED AND SWORN to before me this September 1, 2020, at

Legazpi City by ________________ who is personally known to me that she is
the same person who personally signed before me the forgoing affidavit and
knowledge that she executed the same.

Doc No. ____

Page No.____
Book No. ____
Series of 2021: