REPUBLIC OF THE PHILIPPINES )

PROVINCE OF LAGUNA )
CITY/MUNICIPALITY OF SAN PEDRO ) S.S.

AFFIDAVIT OF LOSS

I, <NAME>, of legal age, Filipino, married, legitimate father of my minor daughter,

<NAME OF DAUGHTER>, and a resident of <ADDRESS>, after having been duly sworn to
in accordance with law, depose and state that:

1. I am a holder of Philippine Passport with No. <XXXX>, issued by the

Department of Foreign Affairs - Manila on <DATE OF ISSUE>;

2. My daughter is a holder of Philippine Passport with No. <XXXX>,

issued by the Department of Foreign Affairs - Manila on <DATE OF ISSUE>;

3. I placed both Passports inside my personal filing cabinet in my

condominium unit;

4. Yesterday, when I was going over my personal records to look for the
abovementioned Passports, I found out that both of the said documents were
already missing. Both must have been lost when we transferred from our
Rizal tower address of the same condominium unit to my new address above
mentioned.

5. Despite diligent search and efforts to locate the said Passports, I could
not find those such that I believe that both are now lost beyond recovery;

6. As such, I am executing this affidavit to attest to the foregoing facts

and to support our application for the issuance of new Passports in lieu of
those which were lost;

7. Affiant further sayeth naught.

IN WITNESS WHEREOF, I have hereunto set my hand this _____ day of __________
2016 in San Pedro, Laguna, Philippines.

________________________________
<NAME>
Affiant

SUBSCRIBED AND SWORN to before me this 29th day of March 2016 in San Pedro,
Laguna, affiant exhibiting to me a copy of his __________ ID with No. ________________.

NOTARY PUBLIC
Doc. No. ____
Page No. ____
Book No. ____
Series of 2016.