That I am 

the lawful holder of Philippine Passport with number ______ issued by theDepartment of Foreign
Affairs, ___________, Philippines which was kept in myshoulder bag. I always bring with me said passport
wherever I go and I used it foridentification purposes
;
 2. That on ____________,
after attending the wake of my friend’s husband
, I decided togo home. While I was preparing my things, I discovered that my passport was missing.I tried to
locate the same within the premises but I found nothing. Also, I asked someof my colleagues if they have the
same but all answered in the negative;3. That I diligently exerted efforts to locate the said passport, but despite
of diligentsearch, it could not be found, hence, the same is deemed lost and at a point beyondrecovery.4. That the
said passport has not been encumbered, sold, pledged, assigned, alienated,transferred, donated, or given as
collateral for any debt or obligation to or in favor ofany person or entity.5. That I understand that my declaration
of the above mentioned passport as lost shall beconstrued as satisfactory proof that the passport was lost, in
compliance with Section15 of RA 8239 of the Philippine Passport Act of 1996.6. That I further understand that
said passport will be immediately deemed cancelled andmay no longer be used for travel or other purposes. As
such, in case the said passportif found or retrieved, undersigned will immediately surrender it to the DFA.7. That
I am executing this affidavit to attest to the veracity of the foregoing facts and forwhatever legal purpose it may
serve under the law.