Republic of the Philippines )

Province of Laguna
)
City of Bian
)
AFFIDAVIT OF LOSS
I, Ramon Oliver B. Sales, of legal age, Filipino citizen and a resident of
Sto. Tomas, City of Bian, Laguna, after being duly sworn in the accordance
with law, depose and state:
1. That last September 16 2015, I was issued by Department of
Foreign Affairs NCR South (Metro Alabang) a Claim Stub and
Receipt for the renewal of my passport;
2. That recently I had tried to look for the Claim Stub and Receipt but
the same could not be found;
3. That despite diligent search and efforts to locate, I could not find
the same such that I now believe it is lost beyond recovery.
As such, I am executing this Affidavit of Loss to attest to the truth of the
foregoing and in support for the claim and renewal of my passport.
IN WITNESS WHEREOF, I hereunto set my hand this _____ of
________________, 2015 at Bian City, Phillippines.
Ramon Oliver B. Sales
Affiant
SUBSCRIBE AND SWORN TO BEFORE ME this ______ of _______________,
2015, in Bian, Laguna, affiant exhibited to me her Community Tax
Certificate No. _________ issued on September 30, 2015 in City of
Bian,Philippines.
Doc No._____
Page No._____
Book No._____
Series of 2015.