Republic of the Philippines)

City of Tarlac ) S.S.

AFFIDAVIT OF LOSS

I, AMOR P. JIMENEZ,of legal age, Filipino, single, and a resident of

77 Happy Hills, Carangian, Tarlac City Philippines, after having been duly
sworn in accordance with law, hereby depose and state:

1. That I am a Customer Associate at LBC SM Tarlac Branch;

2. That sometime on 06 December 2018, our incoming shipments

arrived in our branch including the Passport of Ms. Ronalyn
Eugenio;

3. That on 18 December 2018, Ms. Ronalyn Eugenio went to our

branch to claim her shipment (Passport) but the same could no
longer be found;

4. That despite diligent search and efforts to locate the said

passport, I could not find the same such that I now believe that
it is now lost beyond recovery;

5. I am executing this Affidavit of Loss to attest to the truth of the

foregoing and to support the application for the issuance of new
one in lieu of the one which was lost.

IN WITNESS WHEREOF, I have hereunto set my hand this

_____________ at Tarlac City, Philippines.

AMOR P. JIMENEZ
Affiant

SUBSCRIBED AND SWORN to before me this ________________ at

Tarlac City, Philippines.

Doc No. ________;

Page No. _______;
Book No. _______;
Series of 2018.