REPUBLIC OF THE PHILIPPINES)

CITY OF QUEZON CITY

) S.S.

x----------------------------------x

AFFIDAVIT OF LOSS
I, _______________, of legal age, Filipino, single and a resident of _________________, after having been
duly sworn to in accordance with law, depose and state THAT:

1. On ___________ , I was issued ________ by the __________ in Manila;

2. I was supposed to renew _________ last _________. Unfortunately, my ________ got lost inside the taxi cab
while ____________;

3. Despite diligent search and efforts to locate the said passport, I could not find the same such that I believe that
it is now lost beyond recovery;

4. As such, I am executing this affidavit to attest to the foregoing facts and to support the application for the
issuance of a new one in lieu of the one which was lost.

IN WITNESS WHEREOF, I have hereunto set my hand this September 24, 2013 in Quezon CIty, Metro
Manila, Philippines.

______________
Affiant
ID No. ________

SUBCRIBED AND SWORN TO before me this ___________________ in _________________, Philippines,

affiant exhibiting to me his valid proof of identification.

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 2013.