REPUBLIC OF THE PHILIPPINES )

CITY OF CEBU
)
S.c.

AFFIDAVIT OF LOSS
I, Peachy Cabusas Saldua, of legal age, single, Filipino and residing at M.L.
Quezon Ave., Maguikay, Mandaue City, after being sworn to in accordance with law,
depose and say that:
1.
I was previously issued a Philippine Passport but said travel document
was already expired;
2.

I used to keep the above-mentioned travel document in my bag;

3.
Last September 12, 2007, while I was in the City of Manila looking for
available decent jobs, I accidentally left my bag or misplaced it;
4.
I tried all efforts to locate the misplaced bag together with its contents but I
was not able to find it;
5.

The Passport is now beyond recovery; and

6.
I am executing this sworn statement, as required, to enable me to obtain a
replacement for that Passport.
IN WITNESS WHEREOF, I have hereunto set my hand this ___ day of
__________, 2013, in the City of ____________, Philippines.

PEACHY C. SALDUA
Affiant

JURAT
SUBSCRIBED and sworn to before me, this ___ day of __________, in the City
of __________ by ________________________ with the following competent evidence
of identity:

Evidence of Identity
BIR TIN ID

ID Number
005538058

Issued Date
05/10/2011

Issued At
BIRMandaue
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(TIN No. 247-038-746000)

City

NOTARY PUBLIC
Doc. No. ___;
Page No. ___;
Book No. ___;
Series of 2013.

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