REPUBLIC OF THE PHILIPPINES )

QUEZON CITY
) S.S.
x-------------------------------------------------x
AFFIDAVIT OF LOSS

I, ELPIDIO T. CHAN, JR., Filipino, of legal age, single and with residence at
Blk. 7 Lot 12, Amaresa Subdivision, Francisco Home, Brgy. Guijo, San Jose del
Monte, Bulacan, after having been duly sworn in accordance with law, hereby
depose and say:
1. That I am a holder of Philippine Passport and the number which I could no
longer recall, issued by the Department of Foreign Affairs in Manila;
2. That sometime on June 10, 2015,
nowhere to find;

I discovered that it was lost and

3. That despite diligent search and efforts to locate said document, I could
not find it;
4. That I am executing this affidavit to attest to the truth of the foregoing facts
and to support the application for the issuance of new one in lieu of the
one which was lost.
IN WITNESS WHEREOF, I have hereunto set my hand this _____ day of
____ , 2015 at_____________, Philippines.

ELPIDIO T. CHAN, JR.

Affiant
SUBSCRIBED AND SWORN TO before me this ____ day of _____, 2015
at ___________, affiant exhibiting to me his valid government-issued identification
no. _______________ issued at _________________ and valid until
______________.
Doc. No. _______;
Page No. ______;
Book No. ______;
Series of ______