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Republic of the Philippines)

Province of Cagayan )
Tuguegarao City ) S.S

AFFIDAVIT OF LOSS

I, NENITA USAL, Filipino, of legal age, married, and a resident of #9


Maguigad Street, Atulayan Sur, Tuguegarao City, Cagayan, after being sworn
to in accordance with law, depose and state THAT:

1. I am a holder of a Philippine passport;

2. Together with other pertinent documents, I placed my passport in a


plastic envelope;

3. On September 14, 2018 during the onslaughtof Typhoon Ompong,


we evacuated from our house and fled for our safety from the
incoming flood;

4. After the typhoon, we went back to our house and noticed that
some of our things were ruined and missing including the plastic
envelope were I kept the said passport;

5. The aforementioned situation was a fortuitous event beyond my


control after exercising extraordinary care and diligence;

6. I exerted allefforts to locate and recover the said passport, and the
same is now considered lost for all legal purposes;

7. Considering the foregoing circumstances, it is requested that a new


passport be issued to the undersigned, in lieu of the lost passport,
subject to compliance with the prescribed requirements; and

8. Finally, I am executing this affidavit to attest to the truth of the


foregoing facts and for all legal intents and purpose that it may
serve.

AFFIANT FURTHER SAYETH NAUGHT.

IN WITNESS WHEREOF, I hereto set my hand this 6th of November at


Tuguegarao City, Cagayan, Philippines.

MARY JANE PAJEL-MANGRUBANG


Affiant
SUBSCRIBED AND SWORN to before me this 7th of November at
Tuguegarao City, Cagayan, Philippines, affiant exhibiting to me his
Identification Card, the number written below his name, as proof of his
identity.

Doc. No. _____;


Page No. _____;
Book No. _____;
Series of 2018.