AFFIDAVIT OF LOSS

I, _________________________________, of legal age, Filipino, ____________ (civil

status) and presently residing at ________________________________________, after having
been sworn to in accordance with law, hereby depose and say:

That I was born on ___________________in __________________________________;

That I arrived in Switzerland on _____________________________________as

____________________________________(purpose);

That I was issued passport number __________ on _____________________ in

__________________________;

That said passport was lost (please state when, where and how it was lost)

That I reported the matter to the police authorities in _____________________________

on _______________________________; (OR)

That I did not report the matter to police authorities because

_________________________________________________________________________; and

That I am executing this affidavit to request the Philippine Consulate General in Geneva
to issue me a new passport.

IN WITNESS WHEREOF, I hereunto affix my signature this ________________ 20___,

at Geneva, Switzerland

_________________________
Affiant

THE PHILIPPINE CONSULATE GENERAL )

GENEVA, SWITZERLAND ) S.S.

SUBSCRIBED AND SWORN TO before me this ____________________20__ in

Geneva, Switzerland.

Book No. ________

Doc. No. ________
Page No. ________
Date ________
Fee ________
O.R. No. ________