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.