REPUBLIC OF THE PHILIPPINES )CITY OF_____________________ ) S.S

AFFIDAVIT OF LOSS

I, __________________, Filipino citizen, of legal age, and a resident of ________________________, after been duly sworn in accordance with law, hereby depose and state that:

1. Sometime in _____(month)______ 20__, I was issued a Philippine Passport by the Department of Affairs (DFA) in Manila;

2. I used to put said passport in my pouch;3. That sometime on June 30, 2015, when I arrived home from work, I discovered

that my passport was no longer in my pouch where I used to place it;4. Despite diligent search and efforts to locate the said passport the same had proved

futile;5. That the said passport was not confiscated by the authorities or used in violation

of the law;6. That I am executing this affidavit to attest the truth of the foregoing facts and to

request for a replacement of said Philippine Passport from the DFA.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ____ day of ________________, 2015 at Antipolo City, Philippines.

____________________________ AFFIANT

SUBSCRIBED AND SWORN TO before me, a notary public in and for _________________________ this ____ day of ________________, 2015. The affiant, whom I identified through the following competent evidence of identity: _____________, valid from _____ to _____ issued by _____________, personally signed the foregoing instrument before me and avowed under penalty of law to the whole truth of the contents of said instrument.

NOTARY PUBLIC

Doc. No. _____,Page No. _____,Book No. _____,Series of 2015.