AFFIDAVIT OF LOSS

I, , Filipino citizen, of legal

age and presently residing at
after having been duly sworn to in accordance
with law, hereby depose and state:

1. That I am holder of Philippine Passport No. issued on

2. That sometime around , I noted that the said passport was missing.
(date)

3. That to my knowledge, my passport was lost when

(circumstances or event when passport was lost)

4. That I took great pains to look for the said passport but to no avail.

5. That I had reported the loss of the said passport to the police authority of

IN TRUTH WHEREOF, I have hereunto signed my name below this day of

at the Embassy of the Philippines in Washington DC.

Affiant
Full Name and Signature