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The undersigned, Filipino citizen, single/married, presently residing at

____________________________________________________ after having duly sworn to in
accordance with law, hereby deposes and says:

That the undersigned was issued Philippine Passport No. ________________ by the
Department of Foreign Affairs in Manila/Consular Extension Office/Philippine
Embassy/Consulate in ___________________ on ___________________________;

That said passport was lost on _____________________ under the following


That the undersigned exerted all efforts possible to locate said passport to no avail;

That the undersigned fully understands that the said passport is automatically deemed
cancelled upon declaration of loss, and that if found, it can no longer be used;

That undersigned is executing this affidavit of loss in connection with his/her present
application for a new passport;

That further Affiant/s sayeth none.

IN WITNESS WHEREOF, undersigned hereby affixes his/her signature this

______________ day of _____________ in _________________, USA.


SUBSCRIBED AND SWORN to before me this _________ day of ______________

in _________________, USA. The Affiant having exhibited to me his/her Identification card No.
_______________ issued on ___________________ at _________________________.

Administering Officer/Notary Public