Republic of the Philippines

AFFIDAVIT OF LOSS

I, GEMMA C. ANCHETA, Filipino citizen, of legal age, presently residing at San

Pablo, Narvacan, Ilocos Sur, after having been duly sworn in accordance with the law, do
hereby depose and say:

1. That I lost my Philippine Passport numbered JVI5515 issued in DFA SAN

FERNANDO on April 19, 2007;

2. That I discovered the loss on July 7, 2007;

3. That to my knowledge, my passport was lost when I put my envelope with my passport
inside to my drawer;

4. That I exerted diligent effort in location the said passport, but to no avail;

5. That the said passport has not been encumbered, sold pledged, assigned, alienated,
transferred, donated or given as a collateral for any debt or obligation to or in favor of
any person or entity;

6. That I understand that my declaration of the above mentioned passport as lost shall be
construed as satisfactory proof that the passport was lost, In compliance with the
section15 of R.A.8239 or the Philippine Passport Act. of 1996;

7. That I further understand that said passport will be immediately deemed cancelled and
may no longer be used for travel or any purposes. As such, in case the said passport is
found or retrieved, undersigned will immediately surrender it to the Department of
Foreign Affairs;

8. That I am executing this affidavit to attest to the veracity of the foregoing facts and for
whatever legal purpose it may serve under the law.

IN WITNESS WHEREOF, I have hereunto affixed my signature this 23rd day August
2017 at Narvacan, Ilocos Sur.

___________________________
Affiant

SUBSCRIBED AND SWORN to before me this ______________ at __________