REPUBLIC OF THE PHILIPPINES)

Province of Leyte
) S.S.
City of Tacloban
)
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AFFIDAVIT OF LOSS
I, DIOSHAME CRUZADA SUMACOT, of legal age, Filipino citizen, single with
residence and postal address at Silago, So. Leyte. After having been sworn to in
accordance with law, do hereby depose and state the following:
That I am a holder of Philippine Passport No. EB6953474 issued on December 14,
2012 by the Department of Foreign Affairs in Tacloban City, Philippines.
That I am applying for replacement of my mutilated passport.
That the circumstances surrounding the mutilation of my passport are as following:
o That the passport was one of those documents kept inside my bag which I
placed inside the Bethany Hospital Dormitory for hospital employees and
staff when Supertyphoon Yolanda struck and flooded the whole Bethany
Hospital;
o That I was able to find the bag after the flood subside and saw that the
passport got wet and mutilated;
That I execute this affidavit for the purpose of giving true and correct statement
surrounding the mutilation of my passport.
That further affiant sayeth naught.
IN WITNESS WHEREOF, I have hereunto affixed my signature this 24th day of
October 2014 at Tacloban City, Philippines.

DIOSHAME C. SUMACOT
(Affiant)

SUBSCRIBED AND SWORN to before me, this 24th day of October 2014, by the
Affiant whom I have identified through competent evidence of identity and who exhibited her
PRC ID No. 0425522 issued by PRC Manila on March 28, 2014.

JAYDEE PEREGRINO-CO
Public Attorney I
(Pursuant to R.A. No. 9406)