SEQ CHAPTER \h \r 1REPUBLIC OF THE PHILIPPINES)

___________

) S.S.AFFIDAVIT OF LOSS

I, _________________ (NAME), Filipino, of legal age, with residential address at _______________ (ADDRESS), after having been duly sworn in accordance with law, depose and state:

1. That I was issued a Philippine Passport with passport no. _________, issued on ________ (DATE OF ISSUANCE), in ________ (PLACE OF ISSUANCE);

2. That I arrived here in the Philippines last ________ (DATE OF ARRIVAL);

3. That on ________ (DATE) _______________________ (REASON FOR THE LOSS OF ID)

4. I tried in vain to look for it but all to no avail;

5. I am executing this affidavit to attest to the truth of the foregoing, for the purpose of applying for a replacement passport, and for whatever legal purpose this may serve.

IN WITNESS WHEREOF, I have set my hand this _______ day of __________ (MONTH AND YEAR)

______________________

NAME

SUBSCRIBED AND SWORN TO before me this _______ of _______ (MONTH AND YEAR), affiant personally appearing and known to me to be the same person who executed the foregoing instrument and exhibiting to me his ______________ (ID NO.) , issued on _________ (DATE OF ISSUANCE OF ID). Affiant avows under penalty of law to the whole truth of the contents of the instrument of document.

WITNESS MY HAND AND SEAL.

Doc. No. ________

Page No. ________

Book No. ________

Series of _______