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AFFIDAVIT OF LOSS
I, __________________, Filipino citizen, of legal age, and a resident of
________________________, after been duly sworn in accordance with law, hereby depose and
state that:
1. Sometime in _____(month)______ 20__, I was issued a Philippine Passport by the Department
of Affairs (DFA) in Manila;
2. I used to put said passport in my pouch;
3. That sometime on June 30, 2015, when I arrived home from work, I discovered that my passport
was no longer in my pouch where I used to place it;
4. Despite diligent search and efforts to locate the said passport the same had proved futile;
5. That the said passport was not confiscated by the authorities or used in violation of the law;
6. That I am executing this affidavit to attest the truth of the foregoing facts and to request for a
replacement of said Philippine Passport from the DFA.
____________________________
AFFIANT
NOTARY PUBLIC