REPUBLIC OF THE PHILIPPINES)

_________________ ) S.S.
X----------------------------------------------X

AFFIDAVIT OF LOSS

I, Moises San Jose Facturanan, of legal age, Filipino, married, with office address
at Miyagi-ken Ishinomaki Shi Tachimachi 2 Chrome 4-13, Japan, after having been duly
sworn to in accordance with law, hereby depose and state:

1. That I am the Chief of the Snack BM Morriage Night located at Miyagi-ken

Ishinomaki Shi Tachimachi 2 Chrome 4-13, Japan;

2. That last December 25 2016, I went in a Philippine Restaurant to meet with

friends and I carried along with me my bag wherein I usually put my passport along with
other important documents and personal belongings;

3. Unfortunately, as I was enjoying the night with the company of friends and the
prepared sumptuous dinner, I did not notice that I went home without my bag where I put
my passport and other important documents and belongings;

4. That I have exhausted all diligent efforts to find my passport around my house
and office but to no avail such that I now believe that it was lost beyond recovery;

5. That I execute this Affidavit to attest and declare the truth of the foregoing facts
and to support my request for the processing of my visa.

IN WITNESS WHEREOF, I have hereunto set my hand this _____ day of

_____________ 2016 in ________________ Japan.

Moises San Jose Facturanan

Affiant

SUBCRIBED AND SWORN TO before me this _____ day of _____________

2016 in ___Address_____________________, affiant exhibiting to me his
______________ as proof of competent identity.

Doc. No. _____ ;

Page No. _____;
Book No. _____;
Series of 2016.