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REPUBLIC OF THE PHILIPPINES)

DONE: BAGUIO CITY……………..) S.S.

AFFIDAVIT OF LOSS
(Re; Philippine Passport)

I, HEIDI Q. DACORON, of legal age, single, Filipino Citizen, with


residence and postal address at Interior A, Balacbac, Sto. Tomas Proper,
Baguio City, Philippines, after having been duly sworn to in accordance with
law do hereby depose and states that:

1. I was issued a PHILIPPINE PASSPORT by the Department of Foreign Affairs


(DFA), Baguio City bearing Passport Number EC0564339;

2. My aforementioned passport was lost. When I went to Dagupan, Pangasinan I


placed inside my file envelope (Plastic) my passport. When I came back I
boarded a taxi from Green Valley Junction, Marcos Highway to our house and
went asleep as I was very tired. When I woke-up in the following morning,
January 24, 2017, I noticed that my passport was already missing inside my file
envelope prompting me to inquire at Victory Liner if they had seen it but it
turned negative. Unfortunately I could not remember the trade name and plate
number of the taxi I boarded;

3. I exerted diligent effort to locate the said PHILIPPINE PASSPORT but the same
could no longer be found and hence the passport is considered forever lost;

4. Said PHILIPPINE PASSPORT was never given nor pledged to anyone for any
purpose whatsoever, nor was it taken or confiscated by the authorities for any
violation of the law;

5. I am executing this affidavit to attest to the veracity and truthfulness of my


foregoing statements and for the purpose of securing a new PHILIPPINE
PASSPORT in lieu of the lost one and for other lawful intents and purposes it
may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this 29th day of April, 2017
at Baguio City, Philippines.

HEIDI Q. DACORON
AFFIANT
PhilHealth ID No. 04-050061638-7

SUBSCRIBED AND SWORN TO before me this 29th day of April, 2017 at Baguio
City, Philippines. Affiant personally appeared before me and to be the same person who
executed this instrument freely and voluntarily.

MODESTO T. ANDONG
Notary Public
Commission No. 35-NC-16-R/Until: December 31, 2017
PTR No. 2945281/01-05-2017/Baguio City
IBP No. 1056844/01-05-2017/Baguio-Benguet Chapter
Roll No. 31289/5-15-81/Manila
Doc. No. 371; MCLE COMPLIANCE No. VI-0000192/June 14, 2016
Page No. 75; BIR TIN No. 121-017-652
Book No. XXII; No. 19, 2nd Floor Old Market Bldg.,
Series of 2017. Magsaysay Ave., Baguio City, Philippines