REPUBLIC OF THE PHILIPPINES)

MUNICIPALITY OF AGOO )S.S

PROVINCE OF LA UNION )
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AFFIDAVIT_OF LOSS PASSPORT

I, ___________________, of legal age, Filipino citizen, married and a

resident of Barangay _____________ after being duly sworn, hereby depose and
state:

1. That I am a holder of a Philippine Passport issued by the Department of

Foreign Affairs- ______________;

2. That I kept said passport among my personal files/effects at home;

3. That on June 5, 2016, the 2nd floor of our house at __________________

was engulfed by fire;

4. That among those which were then burnt were my personal files/effects
including my passport;

5. That the said passport is now beyond recovery, hence, considered lost;

6. That said passport was never cancelled, surrendered to or confiscated by any

government authority;

7. That I am executing Affidavit to attest to the truthfulness of the foregoing

and for all legal intents and purposes.

IN WITNESS WHEREOF, I have hereunto set my hand this 20 th day of

August 2021, in the ____________, Philippines.

________________________________
Affiant
DL No. _____________________

SUBSCRIBED AND SWORN TO before me this 20 th day of August 2021,

in the _________________________, Philippines.