Republic of the Philippines)

Santa Cruz, Laguna ) s.s.

AFFIDAVIT OF LOSS

I, _____________,of legal age, Filipino, (single / married / widow), and a

resident of_____________, Philippines, after having been duly sworn in
accordance with law, hereby depose and state:

That on _____________, I was issued a Philippine Passport by the

Department of Foreign Affairs in _____________;

That recently I tried to look for the said passport but the came could not be
found;

That despite diligent search and efforts to locate the said passport, I could
not find the same such that I now believe that it is now lost beyond recovery;

As such, I am executing this Affidavit of Loss to attest to the truth of the

foregoing and to support the application for the issuance of new one in lieu of the
one which was lost.

IN WITNESS WHEREFORE, I hereto affixed my signature this

___________________ in Santa Cruz, Laguna.

JOSELITO G. BATUNGBAKAL
Affiant

SUBSCRIBED AND SWORN to before me this ________________ at Santa

Cruz, Laguna by the affiant with Driver’s License No. N26-01-099223 issued at
LTO Pila District Office, valid until 12 December 2016.

Doc. No. _____; A T T Y. E M M A N U E L E . S A N D I C H O

Page No._____; NOTARY PUBLIC, COMMISSION UNTIL 31 DEC. 2016
Book No._____; NOTARY PUBLIC FOR THE PROVINCE OF LAGUNA
Series of 2016. PER NOTARIAL COMMISSION SP. PROC. NO. 164(15)
IBP O.R. No. 995689, 04 January 2016, Laguna Chapter
PTR O.R. No. 2967138, 04 January 2016, Laguna
Roll No. 42246, admitted to practice law on 9 May 1997
MCLE Compliance No. V-0015412, dated 6 March 2016