Republic of the Philippines )

City of Cagayan de Oro ) S.S.

AFFIDAVIT OF LOSS

I, LOURGEL CAPAPAS DE LA PEÑA, Filipino, 29 years old, single and a resident of

Canitoan, Cagayan de Oro City, after having been duly sworn to an oath in accordance with law, do
hereby depose and say:

1. That I am the lawful holder of a Philippine Passport duly issued by the Department of
Foreign Affairs (DFA), Manila,2 last September 7, 2017;

2. That on March 01, 2020 at about 6:00 in the morning, while I was in Divisoria, Cagayan
de Oro City I did not notice that my passport fell from my bag, which was not securely
closed at that time;

3. That despite diligent and earnest efforts to locate said Philippine Passport, the same
proved futile;

4. That the above-mentioned Philippine Passport is now lost and beyond recovery;

5. That the said Philippine Passport was not encumbered, sold, pledged, assigned, alienated,
transferred, donated, given as collateral for any debt or obligation to or in favor of any
person or entity;

6. That I understand that my declaration of the abovementioned Passport as lost shall be

construed as satisfactory proof that the Passport was lost, in compliance with Section 15
of RA 8239, or the Philippine Passport act of 1996;

7. That I further understand that said Philippine Passport will be immediately deemed
cancelled and may no longer be used for travel or other purposes. As such, in case the
said Philippine Passport is found or retrieved, undersigned will immediately surrender it
to the DFA;

8. That I am executing this affidavit to attest to the truth of the foregoing, to request the
DFA, Cagayan de Oro City for the reissuance of a new Passport, and for whatever legal
purpose this may serve.

IN WITNESS WHEREOF, I have hereunto affixed my signature this 1st day of October
2021, in the City of Cagayan de Oro, Philippines.

LOURGEL CAPAPAS DE LA PEÑA

Affiant
UMID: CRN-0111-6684529-2

SUBSCRIBED AND SWORN to before me on the date and at the place above-written.