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Republic of the Philippines)

Province of Davao Del Sur)s.s.


C I T Y O F D I G O S)
X--------------/

AFFIDAVIT OF LOSS

I, ABC DEF, of legal age, Filipino Citizen, single and a resident of 0056
Aurora Ext., Rebondo Compound Brgy. San Jose Digos City, Philippines, after
having been duly sworn to in accordance with law do hereby depose and say,
THAT:

1. I AM THE SAME AND IDENTICAL person who have caused the


execution of this affidavit;

2. I AM A BONAFIDE HOLDER of a PHILIPPINE PASSPORT issued to


me by the Office of the Department of Foreign Affairs (DFA for brevity);

3. That sometime on May 08, 2014 while on board a bus from Davao
City bound to Digos City I noticed that my wallet which was placed inside my bag
was lost together with pertinent papers and cards;

4. DILIGENT EFFORTS were exerted to locate said passport but to no


avail, hence, this affidavit of loss;

5. I AM EXECUTING this affidavit freely and voluntarily to attest to the


truth and veracity of the foregoing statement and to inform the authorities
concerned of the loss of my passport.

IN WITNESS WHEREOF, I have hereunto set my hand this 02 nd


day of June, 2011 at Digos City, Davao del Sur, Philippines.

ABC DEF
Affiant

SUBSCRIBED AND SWORN to before me this 4 th day of April, 2011 at


Digos City, Davao del Sur, Philippines