Republic of the Philippines)

Ormoc City ) S.S.

AFFIDAVIT OF LOSS

I, JEVELYN AGUIRRE CODILLA, of legal age, Filipino, single and a resident of Brgy. Alta
Vista, Ormoc City, Leyte after having been sworn in accordance with the law, hereby depose
and say:

1. I applied for and was issued a Philippine Passport by the Department of Foreign
Affairs (DFA) Tacloban.

2. That on January 31, 2021, about 4:00 Pm at Brgy. Margen, Ormoc City I discover
that my pouch bag was lost and one of important documents inside was my
Philippine Passport;

3. That I diligently searched for my pouch bag in the place I usually put other similar
documents and in the places I might place it, however despite of my efforts and
time exerted to look for pouch bag, the same proved to be futile as the above-
mentioned pouch bag is nowhere to be found;

4. That I am executing this affidavit in order to attest to the truth of the foregoing and
for any legal purpose this affidavit may serve.

IN WITNESS WHEREOF, I set my hand this March 15, 2021 at Ormoc City,
Philippines. 

JEVELYN AGUIRRE CODILLA

Affiant

SUBSCRIBED AND SWORN TO before me on March 15, 2021at Ormoc City,

Philippines. Affiant exhibiting to her LTO ID NO.HO3-19-006096 valid until 2024-09-09;

Doc. No. _______;

Page No.________;
Book No. _______: Series
of 2021;