REPUBLIC OF THE 

PHILIPPINES )
CITY OF ____________________ ) S.S.

x----------------------------------x
  

AFFIDAVIT OF LOSS 

   I, ----------------------, of legal age, Filipino, single and a resident of

Brgy. Kan Ipa Baybay City, Leyte after having been duly sworn to in
accordance with law, depose and state THAT:

1. On April 22, 2022, I was issued a Philippine Passport with Number

P--------------by the Department of Affairs in NCR WEST;

2. Recently, I had tried to look for the said passport but the same could not be
found;

3. Despite diligent search and efforts to locate the said passport, I could not
find the same such that I believe that it is now lost beyond recovery; 

4. As such, I am executing this affidavit to attest to the foregoing facts and to

support the application for the issuance of a new one in lieu of the one which
was lost. 

IN WITNESS WHEREOF, I have hereunto set my hand

this ___________________ in Makati City, Metro Manila, Philippines.

Affiant

 SUBCRIBED AND SWORN TO before me

this ___________________ in _________________, Philippines, affiant
exhibiting to me his valid proof of identification.

NOTARY PUBLIC

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 2023.