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Republic of the Philippines )

Province of Lanao del Norte)s.s

City of Iligan )
x - - - - - - - - - - - - - - - - - - -x


I, __________________________________________, Filipino, of legal age, single/married, and

a resident of ________________________________________________, after having been duly
sworn to in accordance with law, hereby depose and state:

1. That I am a lawful holder of Philippine Passport bearing No. __________________ issued

by the Department of Foreign Affairs on ____________________________;
2. That sometime in _____________________________________, said passport was
3. That I diligently exerted efforts to locate said passport and other personal belongings, but
in spite of diligent search, it could not be found, hence, the same is deemed lost and at a
point beyond recovery;
4. That the said passport has not been encumbered, sold, pledged, assigned, alienated,
transferred, donated, or given as a collateral for any debt or obligation to or in favor of any
person or entity;

5. That I understand that my declaration of the abovementioned passport as lost shall be

construed as satisfactory proof that the passport was lost, in compliance with Section 15 of
RA 8239 or the Philippine Passport Act of 1996;

6. That I further understand that said passport will be immediately deemed cancelled and may
no longer be used for travel or other purposes. As such, in case the said passport is found
or retrieved, undersigned will immediately surrender it to the DFA; and

7. That I am executing this affidavit to attest to the veracity of the foregoing facts and for
whatever legal purpose it may serve under the law.

IN WITNESS WHEREOF, I have hereunto set my hand this ___ day ______ 2017 at Iligan City,


SUBSCRIBED AND SWORN to before me this _____ day of _____ 2017 at Iligan City,
Philippines, affiant exhibited to me his/her __________________________________ issued on
________________________ by _______________________________.


Notary Public
Until December 31, 2017
Roll No. 61806
IBP No. 101-6261 01/04/17 Iligan City
PTR No. 7288626 01/04/17 Iligan City
MCLE Compliance No. VI-0000324
Doc. No. : ________;
Page No. : ________;
Book No. : ________;
Series of 2017.