A F F I D AV I T

(TO EXPLAIN LOSS/DESTRUCTION OF PHILIPPINE PASSPORT)

AFFIANT: (Please type/print legibly all information requested)

NAME: _______________________________________________________________________
(First Name) (Middle Name) (Last Name/Surname)

Date of Birth: _______________________ Place of Birth: ______________________

Civil Status: (___) Single (___) Married (___) Divorced

(___) Separated (___) Widow (er)

Residence: ________________________________ Tel.# : _____________________________

Passport No. :_____________________ Date of Issue :_______________________________

Place of Issue:_________________________________________________________________

after being sworn according to law, depose and say:

1. That I am a Philippine citizen and holder of Philippine passport described above:

2. That the said passport was (check appropriate box) was (__) lost (__) destroyed under the
following circumstances
(State when, where and how passport was lost or destroyed. If space below is not sufficient,
use reverse side):

___________________________________________________________________________________
____________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________

3. That efforts were exerted to locate the lost passport, but in spite of diligent search, it could
not be found and the same is now beyond recovery. (This paragraph is not applicable to
destroyed passport)

4. That I need a new passport urgently for the following reasons:

__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

5. That in view of the foregoing explanation, it is requested that a new passport be issued to the
undersigned, in lieu of the (__) lost (__) destroyed passport, subject to compliance with
prescribed requirements.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___________ at Vancouver, B.C.,
Canada.

________________________
Affiant

SUBSCRIBED AND SWORN to before me this _____________________ at the Philippine Consulate

General, Vancouver, B.C., Canada.

AFFIANT exhibiting to me his/her identification document:

__________________________
Signing Officer

Doc. No. : _______

Book No. : _______
Page No. : _______
Series : _______
Service No. : _______
Fee : _______