Republic 

of the Philippines )
City of Davao                        ) SS.
x- - - - - - - - - - - - - - - - - -x

AFFIDAVIT OF LOSS
I, NAME, of legal age, Filipino and resident of  Davao City, after having
been duly sworn to in accordance with law hereby depose and state THAT:

1. That on ______________________ our residence ________________ was

burned and destroyed by fire;

2. As a result of the fire, most of our belongings were destroyed or lost,

including my Philippine Passport;

3.  I am executing this affidavit to inform those concerned about the loss

and destruction of my Philippine Passport; and

4.  I attest to the truth of the foregoing facts.

IN WITNESS WHEREOF, we have hereunto affixed our signatures this

____day of ____________ 2021 at ____________, Philippines.

NAME
Affiant

SUBSCRIBED AND SWORN to before me this ________________ in the City

of Davao, Philippines, affiants exhibited to me their government-issued IDs as
valid proofs of identity.

Doc. No. _____

Page No. _____
Book No. _____
Series of 2021.