REPUBLIC OF THE PHILIPPINES }

MUNICIPALITY OF NORZAGARAY } S.S.

PROVINCE OF BULACAN }

AFFIDAVIT OF LOSS
I, JUAN SANTOS, of legal age, Filipino citizen and a resident of Curvada
Minuyan, Norzagaray, Bulacan, after having been duly sworn to in accordance with law,
do hereby depose and state that:

1. I am a holder of an Philippine Passport with no..

2. That I usually put my Philippine Passport in my cabinet located in our living

room for safe keeping.

3. Sometime on November 2018 our barangay was ravaged by flash floods that
damage many houses.

4. That one of the houses that was damaged was my house which was inundated by
water.

5. That all our things in our house were damaged if not lost which include my
passport.

6. I exerted all efforts to locate my passport in our house but I could not find it such
that I now believe that it is now lost and beyond recovery.

7. I hereby execute this affidavit in order to attest to the truth of the foregoing and
for all legal intents and purposes.

IN WITNESS WHEREOF, we have hereunto set my hands this 19 th day of

November 2019, in Norzagaray, Bulacan.

JUAN SANTOS
Affiant
Barangay

SUBSCRIBED AND SWORN to before me this 19th day of November 2019, in

Norzagaray, Bulacan. Affiant exhibited to me her ID with picture and signature as
competent proof of her identity.

Public Attorney II/ Swearing Officer

Public Attorney’s Office
(Pursuant to R. A. 9406)