Republic of the Philippines)

City of Legazpi . . . . . . . . )S.S.

Province of Albay . . . . . . )
x---------------x

AFFIDAVIT OF LOSS
I, MS. A, of legal age, Filipino citizen, married, now
residing at Tektone Village, Legazpi City, after having been
duly sworn to in accordance with law, do hereby depose and
say the following:

1. That I am a holder of Philppine Passport;

2. That October 20, 2020, prior to its expiration, I

applied for the renewal of the said passport;

3. That on December 8, 2020, we transferred

residence at Tektone village, Legazpi City;

4. That after the said transfer, I discovered that the

claim stub for the new passport was missing and
despite earnest effort to locate said claim stub, the
same could no longer be found;
5. That I am executing this Affidavit to attest to the
truth of the foregoing and to be allowed to claim my
new passport despite the absence of the claim stub.

IN WITNESS WHEREOF, I have hereunto set my hand

this 26th day of March, 2021 at Legazpi City, Philippines.

MS. A
Affiant

SUBSCRIBED AND SWORN to before me this 26th day of

March 2021 at Legazpi City, Philippines. Affiant is known to
the undersigned and who exhibited her Driver’s License No.
45678 issued at Legazpi City on May 1, 2020.

Doc. No. 4: ATTY. A

Page No. 4: NOTARY PUBLIC
Book No. 5: Commission Serial No. 1
Series of 2021 Until December 31, 2021
Roll of Attorney 88888
IBP No. 23/May 1, 2018/Manila
PTR No. 28/May 4, 2018/Manila