REPUBLIC OF THE PHILIPPINES )

CAMILING, TARLAC ) S.S.

x----------------------------------------------x

AFFIDAVIT OF LOSS
I, __________, of legal age, Filipino citizen, ___________, and a resident of
Barangay __________________, Philippines, after having been duly sworn to in
accordance with law, hereby depose and state:

1. That I am the lawful holder of Philippine Passport bearing

No._______________, issued by the Department of Foreign Affairs
sometime in the year ________.

2. That on __________ said passport was lost/misplaced.

3. That I diligently exerted efforts to locate the said passport, but spite of diligent
search, it could not be found, hence, the same is deemed lost and at a point
beyond recovery.

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

5. 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 Section 15 of RA 8239 of the Philippine Passport Act of
1996.

6. That I further understand that said passport will be immediately deemed

cancelled and may no longer be used for travel or other purposes. As such,
in case the said passport if found or retrieved, undersigned will immediately
surrender it to the DFA.

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

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

_____ 2018, in the Municipality of ________, Province of _______, Philippines.

_____________
Affiant

SUBSCRIBED AND SWORN to before me this ____ day of _____ 2018, in

the Municipality of ________, Province of __________, Philippines. Affiant
exhibited to me her _____________.

Doc. No.:_______;
Page No.:_______;
Book No.:_______;
Series of 2018.