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SAMPLE AFFIDAVIT OF LOSS

PETITION FOR ADOPTION

WITH APPLICATION FOR CHANGE OF NAME

Petitioner, through undersigned counsel, respectfully states:

1. Petitioner is of legal age, a Spanish citizen, single, and presently residing at 77 A Edades Street,
San Lorenzo Village, Makati City, where he may be served with legal processes. A copy of Petitioner’s
birth certificate is attached herewith as Annex “A” while a copy of Petitioner’s Spanish Passport is
attached herewith as Annex “B”. Petitioner has been residing in the Philippines for at least three (3)
years, or since September 2010.