REPUBLIC OF THE PHILIPPINES )

) S.S.

AFFIDAVIT OF LOSS OF PASSPORT

I, xxxx, Filipino citizen, of legal age and presently residing at

xxxx, after having been duly sworn to in accordance with law,
hereby depose and state:
1. That I am a holder of Philippine Passport issued last 2013;

2. That three (3) days ago, said Passport was misplaced and
got lost;

3. That despite diligent search and efforts to locate my

Passport, I could not find the same, such that I now have
reasons to believe that it is now lost and can’t be recovered;

4. That said Passport has not been confiscated by any

government office for any violation;

5. As such, I am executing this Affidavit of Loss to attest to the

truth of the foregoing and to support my application for the
issuance of a new Passport, in lieu of the one that was lost.
IN WITNESS WHEREOF, I have hereunto signed my name
below this _______________ at _______________, Philippines.

xxxx
Affiant

SUBSCRIBED AND SWORN to before me this _______________

at _______________, Philippines, affiant exhibiting to me her xxxx

Doc. No.: ___;

Page No.: ___;
Book No.: ___;
Series of 2019.