REPUBLIC OF THE 

PHILIPPINES)
PROVINCE OF QUEZON              ) S.S.
x------------------------------------------------x
  
AFFIDAVIT OF LOSS 

         I, RUTH H. CALABIA, of legal age, Filipino, married and a resident Brgy. Poblacion,
Buenavista Quezon:

1. That I am a holder of Passport duly issued in my favor by Department of Foreign Affairs

in Lucena City;

2. That I used to put said passport inside my bag;

3. That sometime on August 20,2022, when I arrived home from work, I discovered that
said passport was no longer inside my bag;

4. That diligent effort to locate the same proved futile;

5. That in view thereof, I now desire and hereby request DFA Lucena to issue another
passport in lieu of the lost one;

6. That I bind myself to save my passport harmless from any loss or damage that it may
incur in connection with the issuance of a new Passport in lieu of the lost one;

7. That I am executing this affidavit to attest to the foregoing facts and for any legal
purpose it may serve.

         IN WITNESS WHEREOF, I have hereunto set my hand this 14th day of October
2022 in Lucena City, Quezon Province, Philippines.

RUTH H. CALABIA
Affiant
Solo Parent ID 0530

    SUBCRIBED AND SWORN TO before me this 14th day of October 2022 in Lucena City,
Quezon Province, Philippines, affiant exhibiting to me his valid proof of identification.
Doc. No. _____;
Page No. _____;
Book No. _____;
Series of 2022.