Republic of the Philippines)

Province of Quirino }
Municipality of Diffun }s.s.

AFFIDAVIT OF LOSS

KNOW ALL MEN BY THESE PRESENTS:

I, MARY JOY PACIS GABRIEL of legal age, Filipino, married, and a

resident of Purok 4 Dabubu Paqueno, San Agustin, Isabela after having
been sworn in accordance with law, hereby deposes and states the
following:

1. I am holder/owner of a Passport CLAIM STUB which I renewed

sometime in April 30, 2014;

2. That I was a holder of of Passport No. WW0017912 before I renewed it;

3. However, when it was time for me to claim the renewed passport, my

claim stub could no longer be found;

4. It is only recently that I realized that said passport claim stub is

irretrievably lost and can no longer be found despite diligent
efforts to locate the same; and

5. I execute this affidavit to attest to the truth of the foregoing.

Signed on the date and at the place indicated below.

MARY JOY PACIS GABRIEL

Affiant
 SUBSCRIBED and SWORN TO before me on the date and at the place
indicated below. The affiant exhibited to me his competent evidence of
identity as indicated above.

Signed this 1st day of February 2018 at Diffun, Quirino.

WITNESS MY HAND AND SEAL.

Atty. MA. KAREN A. BALDONADO-GUILLERMO

Notary Public
Until December 31, 2019
Doc. No. 133 ; PTR No. 3218465/ 01-03-2018
Page No. 28; Lifetime IBP No. 17396/05-20-2017
Book No. 01; ROLL No. 67812/05-26-2017
Series of 2018. MCLE Exemption
(MCLE Governing Board Order No. s-2008)
Diffun, Quirino