REPUBLIC OF THE PHILIPPINES)

CITY OF SAN CARLOS) S.S.

PROVINCE OF NEGROS OCCIDENTAL
x----------------------------x

AFFIDAVIT OF LOSS

I, ROSALIA LAPOT Y SOLATORIO, of legal age, Filipino, single and a

resident of Ylagan St., San Carlos City, Negros Occidental after having been
duly sworn to in accordance with law, depose and state THAT:

1. I am the lawful owner of Passport ID No.

16998854PHL7707261F1307289;

2. That, sometime on December 2019, said passport while in my

possession was lost and misplaced;

3. Efforts were exerted to locate my passbook, but in spite of

diligent search, it could not be found and the same is now beyond
recovery;

4. Said Passport ID was not confiscated by authorities nor any government

agency;

5. As such, I am executing this Affidavit of Loss to attest to the truth of

the foregoing and to support my application/renewal of my Passport
ID;

IN WITNESS WHEREOF, I have hereunto set my hand this 17th Day

of January 2020, at San Carlos City, Philippines.

ROSALIA S. LAPOT
Affiant
DRIVER’S LICENSE No. F10-11-000012

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 SUBCRIBED AND SWORN TO before me this 17TH day of January 2020,
at San Carlos City, Negros Occidental, Philippines, affiant exhibiting to
me his/her competent evidence of identity by way of DRIVER’S LICENSE No.
F10-11-000012.

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 2020.

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