Republic of the Philippines )

City of Iloilo ) S.S.

AFFIDAVIT OF LOSS
OF PASSPORT

I, ANTONIO R. SANTOS III, of legal age, Filipino, married, and a resident

of #37 Sampaguita St., Arevalo, Iloilo, after having been duly sworn to in
accordance with law, hereby depose and state THAT:

1) On May 8, 2001 I was issued a Philippine Passport by the

Department of Foreign Affairs, however, I can no longer recall the
Passport Number of the said Passport;

2) Sometime around January 2017, I noted that the said passport was
missing;

3) To my knowledge my passport was lost when our family home was

subjected to a renovation;

4) I took great pains to look for the said passport but to no avail;

5) Despite diligent search and efforts to locate the said passport, I

could not find the same such that I now believe that it is now lost
beyond recovery;

6) I am executing this Affidavit of Loss to attest to the truth of the

foregoing and to support the application for the issuance of new
one in lieu if the one which was lost.

IN WITNESS WHEREOF, I have hereunto set my hand this December 6,

2017 at Iloilo City, Philippines.

ANTONIO R. SANTOS III

Affiant

SUBSCRIBED AND SWORN TO before me this 6th of December 2017 in

Iloilo, Philippines, affiant exhibiting to me his valid proof of identification.

Doc. No. __________;

Page No.__________;
Book No.__________;
Series of 2017.