Republic of the Philippines)

City of Cebu )S.S.

AFFIDAVIT OF LOSS
I, _______________, Filipino, of legal age, and a resident of Naga City, Cebu,
Philippines, subscribing under oath, hereby depose and state that:

1. I am a holder of a valid Philippine Passport under Passport No. ________

to expire on March 9, 2030 issued by the Department of Foreign Affairs (DFA)-Manila
and a valid Non-Professional Driver’s License No. _________ to expire on March 23,
2022 issued by the Land Transportation Office (LTO).

2. I placed the above-mentioned passport and driver’s license inside my

bag.

3. In the morning of December 16, 2021, as I was shopping for groceries to

prepare myself for the incoming typhoon, I brought my bag containing the above-
mentioned passport and driver’s license including my wallet and other personal items
with me at Ayala Center Cebu. As I was rushing to finish my grocery and after paying
at the cashier, I completely forgot about my bag and could no longer recall where I
placed it last as my mind was centered on my preparation for the incoming typhoon.

4. Unfortunately, despite diligent efforts to locate my bag containing my

passport and driver’s license, I was not able to locate it and the same may now be
considered lost and beyond recovery.

5. Right after the typhoon that hit Cebu City on December 16, 2021, I went
back to Ayala Center to try to locate my bag but the mall was closed due to massive
devastation of its infrastructure.

6. I executed this affidavit to attest to the truth of the foregoing facts and
circumstances and to respectfully request the Department of Foreign Affairs to issue a
new passport under my name in lieu of the lost one as well as to request the Land
Transportation Office to issue a new driver’s license under my name in lieu of the lost
one.

IN WITNESS WHEREOF, I hereunto affix my signature this

________________________ at Cebu City, Philippines.

_________________________
Affiant

SUBSCRIBED AND SWORN TO BEFORE ME this _______________________ at

Cebu City, Philippines; affiant exhibited to me a photocopy of her lost Non-
Professional Driver’s License No. ______________ to expire on March 23, 2022 as proof
of identity.

DOC. NO.
PAGE NO.
BOOK NO.
SERIES OF 2021.