AFFIDAVIT OF LOSS

KNOW ALL MEN BY THESE PRESENTS:

I, juan dela cruz, of legal age, Filipino, single, with address at

_______________________________________, after being duly sworn according to law,
hereby depose and state that:

1. I am the owner of a _____________________, where a Japanese Visa, issued by

the _____________________________ in the Philippines, was attached.

2. Sometime in 2017, I misplaced the above _____________________________

3. Despite diligent efforts exerted, I could no longer locate, find or recover the said
Philippine passport, and to the best of my knowledge, the same is truly lost.

4. The said _________________ has not been confiscated by any officer of the law or
the issuing office or agency due to the violation of any law, statute, order, rule or
regulation.

5. In the event that the lost __________________ should hereafter be found or

located, I undertake to forward the documents to or inform the
______________________________of the Philippines.

6. I am executing this Affidavit to attest to the truth of the foregoing statements and to
request the issuance of a new Japanese Visa in lieu of the one which was lost.

IN WITNESS WHEREOF, I have hereunto set my hand this ___ day of ________ 2017
at Quezon City.

__________________________
Affiant

SUBSCRIBED AND SWORN to before me this ____________________, affiant

exhibited to me his/her Government Issued Identity No. __________________ issued at
______________ on __________________.

Doc. No. ______;

Page No. ______;
Book No. ______;
Series of ______.