REPUBLIC OF THE PHILIPPINES )

CITY OF _____________ . . . . . . . . . ) SS.

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AFFIDAVIT OF LOSS

I, MARY GRACE LAVADIA y MAHOMETANO, of legal age, Filipino and a

resident of Hda. Pili, Brgy. Pacol, Bago City, Philippines, after having been sworn in
accordance with law, do hereby depose and say THAT:

I am a holder of a Philippine Passport issued by the Department of Foreign

Affairs.

Around 9:11 o’clock in the evening of August 15, 2017, my house at Hda. Pili,
Brgy. Pacol, Bago City was burned to the ground.

As a result of the fire, my passport and other important documents and valuables
inside the house were destroyed and lost.

Efforts to retrieve the said passport were done but is now believed to be beyond
recovery.

I am executing this affidavit to the attest to the truth of the foregoing statements.

IN WITNESS WHEREOF, I have hereunto affixed my signature this _____ day of

__________2019, in _________ City, Philippines.

MARY GRACE M. LAVADIA

Affiant

SUBSCRIBED AND SWORN TO BEFORE ME this _____ day of ____________, 2019

in ____________ City, Philippines.