REPUBLIC OF THE PHILIPPINES)

_________________________ ) Sc.
x-----------------------x

AFFIDAVIT OF LOSS

I, _______________________, of legal age, Filipino, married and a resident

of_______________________________, Philippines, after having been duly sworn to in
accordance with law hereby depose and state;

That I am a holder/possessor of Philippine Passport with number 7658765765

which was issued in my favor by the Department of Foreign Affairs-NCR West;

That sometime on _______________________, I discovered the above-stated

Passport was missing probably fell off from my bag while riding a tricycle on my way
home and the same was not recovered;

That despite diligent search and efforts to recover the said passport, I could not
find the same such that I now believe that it is now lost beyond recovery;

That the said passport has not been encumbered, sold, pledged, assigned,
alienated, transferred, donated, or given as a collateral for any debt or obligation to or in
favor on any person;

That I understand that my declaration of the above-mentioned passport as lost

shall be construed as satisfactory proof that my passport was lost, in compliance with
Section 15 of R. A. 8293 or the Philippine Passport Act of 1996;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
facts to support the issuance of a new in lieu of the one which was lost and for whatever
legal purpose that may serve.

IN WITNESS WHEREOF, I have hereunto affixed my signature this

___________________________in _____________________, Philippines.

______________
Affiant

SUBSCRIBED AND SWORN to before me, on the above mentioned date by the
Affiant whom I have identified through competent evidence of identity and who exhibited
his _____________________________.

Doc. No. ____;

Page No. ____;
Book No. ____;
Series of 2022.