Republic of the Philippines )

Province of Pangasinan )
City of Dagupan ) S.S.

AFFIDAVIT OF LOSS
(Airline Ticket)

I, (AFFIANT’S NAME), of legal age, Filipino, married to (NAME OF AFFIANT’S

SPOUSE, if any), and resident of (AFFIANT’S ADDRESS), after having been sworn in
accordance with law hereby deposes and states that:

1. sometime on (DATE OF ISSUE), I bought an Airline Ticket No. (STATE AIRLINE

TICKET NUMBER, if known) from (NAME OF AIRLINE) with an (EN
ROUTE/DESTINATION) being (NAME OF ROUTE OR DESTINATION;

2. sometime on (DATE), I was looking for the said Airline Ticket, but to my surprise,
the same could not be found (ADD, CHANGE OR MODIFY BY INSERTING THE
DETAILS NEEDED ACCORDING TO THE CIRCUMSTANCES);

3. despite earnest and painful efforts on my part to search, locate and retrieve the
aforesaid Airline Ticket, the same proved me futile and in vain;

4. said Airline Ticket was not confiscated by any officer of the law or the officers of the
(NAME OF AIRLINE) by reason of any violation of any law, ordinance, presidential
decree or rules and regulations of the said airline; 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 from the
(NAME OF AIRLINE) a replacement copy of the said Airline Ticket, and for all
legal intents and purposes this may serve.

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

_______________, 20___ in the City of Dagupan, Province of Pangasinan, Philippines.

_________________________________
(AFFIANT’S NAME)
Affiant