REPUBLIC OF THE PHILIPPINES )

PROVINCE OF TARLAC ) S.S.

AFFIDAVIT OF LOSS

I, ________________________, of legal age, Filipino, single, with residence

and postal address at ___________________________________________________,
after being sworn to in accordance with law, hereby depose and say:

1. That as a citizen of the Republic of the Philippines, I applied and was

issued a Philippine Passport on September 2019, by the Department
of Foreign Affairs (DFA), in accordance with the pertinent laws of the
Republic;

2. That at the time of issuance until present, I have all of the

qualifications and none of the disqualifications for the renewal of my
passport or issuance of a new one;

3. That sometime on October 2019, I lost the above-mentioned

passport, which I last saw at my envelope, where I usually kept the
same;

4. That the said passport was never found until present despite all
efforts exerted for its recovery;

5. That the same is beyond recovery, and is considered as lost; and

6. As such, I am executing this instrument to attest to the truth of the

foregoing narrated facts, as a requirement of the Department of
Foreign Affairs (DFA), and for whatever legal purpose it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this

_____________________ at Concepcion, Tarlac, Philippines.

________________________
Affiant

SUBSCRIBED AND SWORN to before me, this _______________________ at

Concepcion, Tarlac, Philippines, by the Affiant whom I have identified through
____________________________________________________________________, who is the same
person who personally signed and executed this Document.

Doc. No: _________

Page No: _________
Book No: _________
Series of 2019.