REPUBLIC OF THE PHILIPPINES )

PROVINCE OF CAVITE ) S.S.

CITY OF DASMARINAS )

AFFIDAVIT OF LOSS

I, ARLENE G. DEYPALUBOS, of legal age, Filipino citizen, and with

residence and postal address at Block 97 Lot 31 Golden Horizon Homes
Pabahay, Hugo Perez, Trece Martires City, Cavite, after having been duly
sworn to according to law, do hereby freely states:

1. THAT, I was issued a Philippine Passport by the Department of

Foreign Affairs (NCR East) on February 23, 2018 until February 22, 2028;

2. THAT, upon receipt of my said passport, I used the same for

application for working at abroad and submitted the said passport to my
employer in Saudi Arabia as per their rules and for safe keeping;

3. THAT, sometime in August 23, 2020, I was one of the OFW’s who
was forced to undergo mandatory repatriation due to Covid-19 pandemic and
was failed to get my Philippine Passport from my employer and I only used a
travel document issued by the Philippine Embassy. I exerted diligent efforts to
talk to my employer to retrieve my Philippine Passport but all of my efforts were
in vain, for this reason, I consider my Philippine Passport as lost and/or
destroyed;

4. THAT, I executed this Affidavit of Loss to attest to the truthfulness

of the foregoing and to support my request to the Department of Foreign Affairs,
Passport Department, to issue a new Philippine passport in the name of
ARLENE G. DEYPALUBOS in lieu of the one lost and for whatever legal
purpose it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this 15th day of

July 2022 at Dasmarinas City, Cavite.

ARLENE G. DEYPALUBOS
Affiant

SUBSCRIBED AND SWORN to before me this 15th day of July 2022 at

Dasmarinas City, Cavite. Affiant exhibited to me her TIN ID with No. 277-015-
405-00000 issued on 30 September 2021 as her competent proof of identity.

NOTARY PUBLIC
Doc. No. ____;
Page No. ____;
Book No. ____;
Series of 2022.