Republic of the Philippines)

City of Cotabato. . . . . . . . .)S.S

Province of Maguindanao. )

AFFIDAVIT OF LOSS
I, JAISA T. MAMITES, Filipino, of legal age, single and a resident of 3 rd Blk Palar, Awang,
Datu Odin Sinsuat, Maguindanao after having been duly sworn to in accordance with law, do
hereby depose and say:
1. That I was born in Lucena City on April 29, 1989;
2. That my fathers name is Jaime D, Mamites a citizen of the Philippines and my
mothers name is Saturnina A. Tamparong, also a citizen of the Philippines;
3. That I am a holder of Philippine Passport No. EC01414697 which was issued on
February 26, 2014 at the the Philippine Embassy in Tripoli, Libya by the Department
of Foreign Affairs;
4. That the circumstances about the loss of my Philippine Passport are as follows:
On 05 June 2015 at Awang, Municipality of Datu Odin Sinsuat,
Maguindanao, I learned that the said passport was missing.
5. That unable to find said passport despite diligent search to locate the same, I
reported its loss to the Philippine National Police as evidenced by the attached Police
Report hereto attached as ANNEX A and ;
6. That I am executing this affidavit for the information of all the authorities concerned
and for the purpose of applying/ renewal for a new passport with the Department of
Foreign Affairs.
IN WITNESS WHEREOF, I have hereunto affixed
______________________in Cotabato City, Philippines.

my

signature

on

this

JAISA T. MAMITES
Affiant
SUBSCRIBED AND SWORN to before me this _________________________ in
Cotabato City Philippines affiant having exhibited to me his COMELEC Voters ID No. 3807-0035AD2989JTM20000.

Doc. No. _______

Book No. _______
Page No.________
Series of 2015