Republic of the Philippines )

Metro Manila ) S.S.

City of Quezon )

AFFIDAVIT OF LOSS
(Passport)

I, GLENN E NIEVES, of legal age, Filipino, single, and resident of Alabug Tuao
Cagayan Valley, after having been duly sworn in accordance with law hereby
deposes and states that:

1. I am the true and lawful owner of a Passport No. UU0724226 Type P

issued on April 25, 2007 by the Department of Foreign Affairs;

2. Sometime on April 9, 2013, I was looking for the said Passport, but to my
surprise, the same could not be found;

3. Despite earnest and painful efforts on my part to search, locate and

retrieve the aforesaid Passport, the same proved me futile and in vain;

4. Said Passport was not confiscated by any officer of the law or by the
Philippine Embassy by reason of any violation of any law, ordinance,
presidential decree or rules and regulations of the same; neither was it
offered as collateral for any loan nor transferred to any person or entity
nor used for any unlawful purpose; and

5. I am executing this affidavit to attest to the truth of the foregoing, to

request a replacement copy of the said Passport and for all legal intents
and purposes this may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this 27th day of

February, 2017 in the City of Quezon, Philippines.

GLENN E NIEVES
- Affiant -

SUBSCRIBED AND SWORN to before me this 27 th day of February 2017 at

Quezon City, Philippines.