REPUBLIC OF THE PHILIPPINES )

CITY OF CEBU ) S.S

AFFIDAVIT OF LOSS

I, ________________, of legal age, Filipino, single and a resident of

_________________________, after having been duly sworn to in accordance with
law, depose and state THAT:

1. On July 11, 2012, I was issued a Philippine Passport bearing Passport

No. EB5905119 by the Department of Affairs in Cebu City;

2. On January 23, 2017, I noticed that my Passport is no longer in its

usual place. I had tried to look for the said passport but the same could
not be found;

3. Despite diligent efforts exerted, I could no longer locate, find, or

recover the said Passport, and to the best of my knowledge, the same
is truly lost;

4. As such, I am executing this affidavit to attest to the foregoing facts

and to support the application for the issuance of a new one in lieu of
the one which was lost.

IN WITNESS WHEREOF, I have hereunto set my hand this

___________________ in Cebu City, Philippines.

____________________
Affiant

SUBSCRIBED AND SWORN to before me this _____ day of

_________________ at Cebu City, Philippines. Affiant personally appeared and
exhibited to me his ______________________________.

Doc. No. _____

Page No. _____
Book No. _____
Series of 2017.