AFFIDAVIT: LOSS OF PASSPORT

REPUBLIC OF THE PHILIPPINES )

Consulate General of the Philippines ) s.s.
New York, New York )

AFFIDAVIT OF LOSS OF PASSPORT

I, , Filipino, of
legal age, single / married to and a resident of
, after having
been duly sworn in accordance with law, hereby voluntarily depose and say:

1. That I was born on in ,

Philippines / Other , to the following parents:

FATHER MOTHER
Name:
Place of Birth:
Date of Birth:
Citizenship:

2. That I applied for and was issued Philippine Passport Number

in on ;

3. That I entered the United States on a/n type-visa

on (date) with (city) as my port of entry;

4. That said passport is no longer in my possession due to the following circumstances:

(may be continued at the back page);

5. That I fully understands that the moment the passport is declared lost or stolen, it is
automatically deemed cancelled and that if found, it can no longer be used to avoid
complications with immigration authorities; and

6. That I am executing this affidavit to attest to the truth and veracity of the foregoing facts
in connection with my application for a Philippine passport.

SIGNED on in New York City.

PHOTO
AFFIANT

SUBSCRIBED AND SWORN TO before me this day of in

the City of New York.