AFFIDAVIT OF LOSS OF PASSPORT

I,_______________________________ , Filipino citizen, of legal age and presently residing at

___________________________________________________________________________________
after having been duly sworn to in accordance with law, hereby depose and state:

1. That I am a holder of Philippine Passport No. _____________________ issued on

____________________ at ____________________________;

2. That the circumstances surrounding the loss of my passport are as follows:

__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
________________________________________________________________________.

3. That I execute this affidavit for the purpose of giving true and correct statement surrounding
the loss of my passport.

IN WITNESS WHEREOF, I have hereunto signed my name below this day of

_________________ at __________________________.

___________________________
Affiant
(Full Name and Signature)

SUBSRIBED AND SWORN to before me this day of ________________________, at

__________________________, affiant exhibiting to me his/her valid proof of identification.

Doc. No. : ________

Service No.: ________
Book No. : ________
Series of : ________ __________________________
Fee Paid : ________ Consular Officer
O.R. No. : ________