REPUBLIC OF THE PHILIPPINES)

___________________________ ) SS.

AFFIDAVIT OF LOSS

I, __________________, of legal age, a Filipino citizen, with residence

address at ______________________________________________, after
being first duly sworn in accordance with law, do hereby depose and state:

1. That I am the holder of Philippine Passport No. _________

issued at __________ on ______________;

2. That said Passport was misplaced in our residence, was

subsequently lost, and despite diligent search, can no longer be found; and

3. That I am executing this affidavit to attest to the truth of the

foregoing, and for the purpose of securing a new passport from the
Department of Foreign Affairs.

IN WITNESS WHEREOF, I have hereunto affixed my signature, this

____ day of May 2017 at ______________________.

_________________
Affiant

SUBSCRIBED AND SWORN to before me at ____________, Metro

Manila, Philippines, this ____ day of _______, 2017 affiant exhibiting to me
her valid proof of identity consisting of:
__________________________________
_______________________________________.

Doc.No. _____;
PageNo. _____;
BookNo. _____;
Series of 2017.