REPUBLIC OF THE PHILIPPINES)

___________ ) S.S.

AFFIDAVIT OF LOSS

I, _Danielle Kym Marie R. Algarme__ (NAME), Filipino, of legal age, with

residential address at _lot 9 block 4 JMPV Subdivision Talungon, Bais City, Negros
Oriental__ (ADDRESS), after having been duly sworn in accordance with law, depose and
state:

1. That I was issued a Philippine Passport with passport no. P1121418A , issued
on December 7, 2016 (DATE OF ISSUANCE), in DFA NCR EAST (PLACE OF
ISSUANCE);

2. That I arrived here in the Philippines last April 1 2017 (DATE OF ARRIVAL);

3. That on January 21 2018 (DATE) I have misplaced the location of my passport

(REASON FOR THE LOSS OF ID)

4. I tried in vain to look for it but all to no avail;

5. I am executing this affidavit to attest to the truth of the foregoing, for the purpose
of applying for a replacement passport, and for whatever legal purpose this may serve.

IN WITNESS WHEREOF, I have set my hand this 18th day of February 2018
(MONTH AND YEAR)

_Danielle Kym Marie R. Algarme

NAME

SUBSCRIBED AND SWORN TO before me this _18th__ of __February 2018_

(MONTH AND YEAR), affiant personally appearing and known to me to be the same person
who executed the foregoing instrument and exhibiting to me his Student ID 17-4136 (ID NO.)
, issued on August 16 2017_ (DATE OF ISSUANCE OF ID). Affiant avows under penalty of
law to the whole truth of the contents of the instrument of document.

WITNESS MY HAND AND SEAL.

Doc. No. ________

Page No. ________
Book No. ________
Series of _______