REPUBLIC OF THE PHILIPPINES )

___________________ ) S.S.
x----------------------------------------------x

AFFIDAVIT OF LOSS
I, _________________, __ years of age, Filipino citizen, single, and a resident of
Barangay _________________, Philippines, after having been duly sworn to in accordance
with law, hereby depose and state:

1. That I am the lawful holder of Philippine Passport with number ______ issued by the
Department of Foreign Affairs, ___________, Philippines which was kept in my
shoulder bag. I always bring with me said passport wherever I go and I used it for
identification purposes;

2. That on ____________, after attending the wake of my friend’s husband, I decided to

go home. While I was preparing my things, I discovered that my passport was missing.
I tried to locate the same within the premises but I found nothing. Also, I asked some
of my colleagues if they have the same but all answered in the negative;

3. That I diligently exerted efforts to locate the said passport, but despite 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 collateral for any debt or obligation to or in favor of
any person or entity.

5. That I understand that my declaration of the above mentioned passport as lost shall be
construed as satisfactory proof that the passport was lost, in compliance with Section
15 of RA 8239 of 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
if found or retrieved, undersigned will immediately surrender it to the DFA.

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 __th day of January, 2019
in the Municipality of _______, Province of _________, Philippines.

___________________
Affiant

SUBSCRIBED AND SWORN to before me this __th day of January 2019, in the
Municipality of ___________, Province of __________, Philippines. Affiant exhibited to me
his/her ______________ issued by the ________________.