Republic of the Philippines ]

City of Tagbilaran ] S.S.

AFFIDAVIT OF LOSS

I, GEORGE DOLLER CESPON, Filipino, of legal age, married and a resident of

Tagbilaran City, Bohol, Philippines, after being sworn in accordance with law, hereby depose and
say:

That I am a bonafide holder of an expired Philippine Passport duly issued by the

Department of Foreign Affairs (DFA), Consular Office Cebu City;

That my said Philippine Passport was lost/misplaced;

That I exerted diligent efforts to find and recover my Philippine Passport, however, my
efforts proved futile as until now, its whereabouts still could not be ascertained, hence, I
considered it to be lost, for all intents and purposes;

That my said Philippine Passport was not confiscated by lawful authorities for violation
of immigration and other laws;

That I execute this affidavit voluntarily to attest to the truth of the foregoing statements to
support the renewal and subsequent issuance of another passport in my name by the Department
of Foreign Affairs (DFA) in lieu of the lost one;

That further, I execute this affidavit for whatever legal purpose that this may serve.

IN WITNESS WHEREOF, I hereunto set my hand this ___________________ at

Tagbilaran City, Bohol, Philippines.

GEORGE DOLLER CESPON

Affiant
VIN: 1242-0044A-H125GDC10000
Issued by COMELEC-Tagbilaran City, Bohol

SUBSCRIBED AND SWORN to before me this ___________________ at Tagbilaran

City, Bohol, Philippines.

Doc. No. ________;

Page No. ________;
Book No. ________;
Series of 2016.