Republic of the Philippines)

City
of
Mandaue )s.s.

AFFIDAVIT OF LOSS
I,
___________________________,
Filipino,
of
legal
age,
single/married, and with residence and postal address of
_____________________________, Philippines, under oath, hereby depose
and say:
1. That I was issued a Philippine Passport by the Department of
Foreign Affairs-Consular Office, ___________ with Passport Number
___________ which I have kept in my files.
2. That very recently, I discovered that said
inadvertently lost and can no longer be located.

Passport

was

3. Diligent efforts were exerted to find the same but to no avail.

4. I further attest that it was lost beyond my control and was never
confiscated by any lawful authorities for any violation of law,
rules or regulations.
5. This affidavit is executed to establish the veracity of the
foregoing facts in order to request the Department of
Foreign Affairs to issue a new Passport and for whatever
legal purpose it may serve.
IN WITNESS WHEREOF, I have hereunto set my hand this ___
day of ______________ 2015 at Mandaue City, Philippines.

___________________________
Affiant
I.D. Type/No. ______________
___________________________
SUBSCRIBED AND SWORN TO, before me this ___ day of
____________ 2015 at Mandaue City, Philippines, affiant exhibited
his/her Competent Proof of Identity, details written below his/her
name.

Doc. No. _______;

Page No. _______;
Book No. _______;
Series of 2015.

ATTY. ISRAEL CAMAHALAN NOMBRADO

NOTARY PUBLIC
For the City of Mandaue & for the Municipalities
of Consolacion, Lilo-an, Compostela & Cordova
Zamora St., Centro, Mandaue City 6014
NOT. COM. NO. 2014-49
Until December 31, 2015
PTR No. 5829397 / 1-05-15 / Mandaue City
IBP No. 0982066 / 01-08-2015 / Cebu Chapter
Roll No. 62747 / Tel # (032) 5142880
TIN: 910-900-854-000