REPUBLIC OF THE PHILIPPINES ) 

PROVINCE OF LEYTE ) S.S.

CITY OF TACLOBAN )

AFFIDAVIT OF LOSS

I, Engr. John Rey , of legal age, Filipino citizen, married, and a resident of

Barangay ________________, Philippines, after having been duly sworn to in accordance
with law, hereby depose and state:
 
1. That I am the lawful holder of Philippine Passport issued by the Department of
Foreign Affairs, Tacloban City, Philippines, on January 2014, which was kept in my
drawer where I usually safe keep my important documents;

2. That on January 18, 2023, I was going thru my important documents, I discovered

that my passport was missing. I tried to locate the same within the premises but I
found nothing. Also, I asked the members of my household if they have seen my
passport but all answered in the negative;

3. That I diligently exerted efforts to locate the said passport, but despite of diligent
search, it could not be found, hence, the same is deemed lost and at a point beyond
recovery;

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 of any person or entity;

5. That I understand that my declaration of the above mentioned passport as lost shall

be construed 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 and may no longer be used for travel or other purposes. As such, in case
the said passport if 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 for
whatever legal purpose it may serve under the law.

IN WITNESS WHEREOF, I have hereunto set my hand this ________________, at

Tacloban City, Philippines.

___________________
Affiant

SUBSCRIBED AND SWORN to before me this _______________ at

Tacloban City, by Engr. John Rey, who is personally known to me, and is the
same person who personally signed before me the foregoing affidavit and
acknowledged that he executed the same.

Doc. No. ____;

Page No. ____;
Book No. ____;
SERIES OF ____.