REPUBLIC OF THE PHILIPPINES)

ANGELES CITY
)S.S.

AFFIDAVIT OF LOSS
I, ROSEMARIE S. DEYPALUBOS, Filipino, single, of legal age and with
residence at Purok 5, Balaybay Resettlement, Castillejos, Zambales, after
being duly sworn to in accordance with law, hereby depose and say, thus:
1. I am a duly owner and holder of a Philippine Passport, Drivers
License, Firearm License of 9mm Pistol, Permit to Carry 9mm Pistol, Official
Receipt and Certificate of Registration of Honda Bravo;
2. I kept said documents inside my hand bag;
3. That on May 11, 2015, I was riding a tricycle from Don Bonifacio
Subd., Angeles City to SM Clark, Angeles City, bringing with me the said hand
bag;
4. That I inadvertently left my hand bag inside the tricycle I was riding
on;
5. That despite search and efforts to locate said tricycle, I could not
find the same as I do not remember the Plate Number and such that I now
believe that my hand bag is now lost beyond recovery;
6. As such, I am executing this Affidavit of Loss to attest to the truth of
the foregoing and to support my application for the issuance of a new
Philippine Passport, Drivers License, Firearm License of 9mm Pistol, Permit to
Carry 9mm Pistol, Official Receipt and Certificate of Registration of Honda
Bravo, in lieu of the one that was lost.
IN WITNESS WHEREOF, I have hereunto set my hand this 11 th day of
May 2015 at Angeles City, Philippines.
ROSEMARIE

S.

DEYPALUBOS
Affiant
SUBSCRIBED AND SWORN TO before me this 11th day of May 2015
at Angeles City, Philippines. Affiant personally known to me.