REPUBLIC OF THE PHILIPPINES )

CITY OF CALOOCAN )S.S.

AFFIDAVIT OF LOSS

KNOW ALL MEN BY THESE PRESENTS:

I, ______, of legal age, widow, and a resident of _______Caloocan City, after
having sworn to in accordance with law, hereby deposes and states:
1. That I am the owner of Passport No. _________________;

2. That on or about March 2018, our then house was flooded which constrained
us to move to a different residence;

3. That the said passport was among our belongings which was damaged and lost
by reason of the said flood;

4. That I exerted utmost effort and diligence to locate, preserve, and save the
said passport, but to no avail.

5. That I am executing this affidavit to attest to the truth of the foregoing and to
request the Department of Foreign Affairs an issuance of a new passport.
IN WITNESS WHEREOF, I have hereunto set my hand and this _________ day
of _______. 20___ at ____________.

____________

SUBSCRIBED AND SWORN TO BEFORE ME this ______ day of ________, 20 ___

in _____________ City, with affiant exhibiting her _________________issued on ______ at
__________.

NOTARY PUBLIC

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