Republic of the Philippines)

Tanay, Rizal ) S.S.

x----------------x

AFFIDAVIT OF LOSS

I, ______________________, of legal age, Filipino, widow), and a resident

___________________________, Philippines, after having been duly sworn in accordance
with law, hereby depose and state:
That in year 2010, I was issued a Philippine Passport by the Department of Foreign
Affairs in Davao City;
That since 2012 I had tried to look for the said passport but could not be found;
That despite diligent search and efforts to locate the said passport, I could not find the
same such that I now believe that it is now lost beyond recovery;
As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing and
to support the application for the issuance of new one in lieu of the one which was lost.
IN WITNESS WHEREOF, I have hereunto set my hand this _____________ at
_____________, Philippines.

Affiant

SUBSCRIBED AND SWORN before me this ____day of ___________ 2020, by

___________________ who exhibited to me his________________________ issued on
________________________ at ____________________.

Doc No. ________________;

Page No. _______________;
Book No. ______________;
Series of 2020.