REPUBLIC OF THE PHILIPPINES)

CITY OF MAKATI ) S.S.

AFFIDAVIT OF LOSS

I, ELLEN A. ADARNA, of Legal Age, Filipino, Married, born on with

residential address at 316 Palin St., Block 27, Lot 77, Ai- Ai, General Tinio,
GMA, Cavite, subscribing under oath, hereby depose and state:

1. That I am the holder of a valid Philippine Passport issued by the

Department of Foreign Affairs;

2. That last December 23, 2012, I placed the aforesaid passport inside
my bag while I am at the Central, Commonwealth, Quezon City;

3. That when I looked for the passport inside my bag, I could no longer
locate it;

4. That my said passport could not be found notwithstanding diligent

efforts to locate the same and is now considered lost for all legal intents and
purposes;

5. That I certify this oath to report the loss of my Philippine Passport

issued by the Department of Foreign to avoid the said missing passport from
being used for illegal purposes by other persons; 6. That I execute this
affidavit to attest to the truth of all the foregoing facts and for securing a new
Philippine passport.

Affiant further says none.

ELLEN A. ADARNA
Affiant
________________________________________
________________________________________
 BEFORE ME, appears the person of ELLEN A. ADARNA presenting the
above Affidavit, who is personally known to me or identified by me through
competent evidence of identity as defined by the Notarial Rules as the
person who signs the document and in my presence taken an oath or
affirmation before me as to such document. WITNESS MY HAND AND
SEAL this 8th day of January, 2014 in Imus City, Cavite

Doc. No. ____;

Page No. ____;
Book No. ____;
Series of 2014.