Republic of the Philippines )

City of Dipolog ) S.S

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

AFFIDAVIT OF LOSS

I, MARILYN CUSTADO CALIBO, Filipino, of legal age, widow and a resident of

Purok Chrismus Bucana, Sicayab, Dipolog City, after having duly sworn in accordance
with law, do hereby depose and state THAT:

1. That I am the holder of Passport issued by Department of Foreign Affairs

(DFA), however, I can no longer recall the Passport Number of the said
Passport;

2. Sometime around October 2018, the said passport was missing and got lost;

3. That I had tried to look for the said passport but the same could not be
found;

4. 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;

5. 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 WHEREOF, I have hereunto affixed our hands this 6th day of March
2019 at Dipolog City, Philippines.

MARILYN CUSTADO CALIBO

Affiant

SUBSCRIBE AND SWORN to before me this 6th day of March 2019 at Dipolog City,
Philippines, with affiant exhibiting to me her ID NO. PGZN-2220826, issued at Dipoolog
City, Zamboanga del Norte.

Doc. No.
Page No.
Book No. II
Series of 2019
Republic of the Philippines )
City of Dipolog ) S.S
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AFFIDAVIT OF LOSS

I, FREDERICK S. CALOG, of legal age, Filipino, married and a resident of

Barangay Alvinda, Mutia, Zamboanga del Norte, after having duly sworn in accordance
with law, do hereby depose and state that:

1. That I am a holder of an Official Receipt from a purchase of a chainsaw in

Oroquieta City in the year 2017 which is more particularly described as
follows:
BRAND SERIAL MACHINE NO.

ZERO70 STEEL S178200084

2. That the said document while in my possession was misplaced and could no
longer ne located inspite of exerting efforts of locating them;

3. That I am executing this affidavit to attest the truth of the foregoing and for
whatever legal purpose it may serve.

AFFIANT FURTHER SAYETH NAUGHT.

IN WITNESS WHEREOF, we have hereunto affixed our hands this____ day of

_______________ at ________________.

FREDERICK S. CALOG
Affiant
Philhealth ID 16-050166521-2

SUBSCRIBE AND SWORN TO before me this August 31, 2018 at Dipolog City.

Doc. No.___
Page No.___
Book No.___
Series of 2018.