REPUBLIC OF THE PHILIPPINES)

___________
) S.S.

AFFIDAVIT OF LOSS
I, _________________ (NAME), Filipino, of legal age, with residential address at
_______________ (ADDRESS), after having been duly sworn in accordance with law,
depose and state:
1. That I was issued a Philippine Passport with passport no. _________, issued on
________ (DATE OF ISSUANCE), in ________ (PLACE OF ISSUANCE);
2. That I arrived here in the Philippines last ________ (DATE OF ARRIVAL);
3. That on ________ (DATE) _______________________ (REASON FOR THE
LOSS OF ID)
4. I tried in vain to look for it but all to no avail;
5. I am executing this affidavit to attest to the truth of the foregoing, for the purpose
of applying for a replacement passport, and for whatever legal purpose this may serve.
IN WITNESS WHEREOF, I have set my hand this _______ day of __________
(MONTH AND YEAR)

______________________
NAME
SUBSCRIBED AND SWORN TO before me this _______ of _______ (MONTH
AND YEAR), affiant personally appearing and known to me to be the same person who
executed the foregoing instrument and exhibiting to me his ______________ (ID NO.) ,
issued on _________ (DATE OF ISSUANCE OF ID). Affiant avows under penalty of law to
the whole truth of the contents of the instrument of document.
WITNESS MY HAND AND SEAL.

Doc. No. ________

Page No. ________
Book No. ________
Series of _______