Republic of the Philippines)

City of Roxas ) S. S.
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AFFIDAVIT OF LOSS

I, PAOLO NIKKI C. BAGARES, of legal age, single, and a resident of Brgy.

Poblacion Sur, Ivisan, Capiz, Philippines after being duly sworn to in accordance with
law, hereby depose and say:

1. That I am a holder of Seaman’s Book (SIRB) issued by the Marina Manila and
Philippine Passport issued by the Department of Foreign Affair (DFA) Iloilo.

2. That I kept my said Seaman’s Book and Passport in my pouch, for me to be

able to easily locate it whenever I needed the same.

3. That last December 16, 2015 when I traveling from Ivisan, Capiz going to
Roxas City, I discovered that my pouch containing my Seaman’s Book and
Passport was missing.

4. That, recently, I look for my Seaman’s Book and Passport that was issued to
me before, however, despite diligent efforts to locate the same, such was in
vain for I never locate the above-mentioned documents.

5. That after such discovery, I had exerted honest to goodness and earnest
efforts to locate and find the same, but to no avail.

6. That I hereby consider now my said seaman’s book and passport to be lost
and beyond recovery.

7. That I am executing this affidavit under pain of perjury to attest to the truth
and veracity of the foregoing statements, and for the purpose of requesting
the Marina Manila and Department of Foreign Affairs, to issue a replacement
of my lost seaman’s book and passport and for all legal intents and purposes
this affidavit may serve best.

IN WITNESS WHEREOF, I have hereunto set my hand this ___________ in the

City of Roxas, Capiz, Philippines.

PAOLO NIKKI C. BAGARES

Affiant

The affiant, whose name and personal circumstances are stated above, appeared
in person before me this __________________, in the City of Roxas, presented the
above instrument, signed the same in my presence, and affirmed or swore under oath
to the truth and correctness of the contents or allegations of the same. The affiant was
personally known to me and he exhibited to me his Competent Evidence of Identity PRC
ID No. D3-0075380.

Doc No._______
Page No. ______
Book No. ______
Series of 2015