AFFIDAVIT OF LOSS

REPUBLIC OF THE PHILIPPINES)

_____________________________ ) S.S.

I, ROMMEL D. VILLAMOR, married, of legal age and a resident of Siniloan, Laguna, after
having sworn to in accordance with law do hereby depose and states that:
I am the holder of a Philippine passport issued by the Department of Foreign Affairs.
I lost the above passport during one of the typhoons that flooded our house;
Despite diligent efforts exerted, I could no longer locate, find or recover the said passport,
and to the best of my knowledge, the same is truly lost.
The said passport has not been confiscated by any officer of the law or the issuing office
or agency due to the violation of any law, statute, order, rule or regulation.
In the event that the lost passport should hereafter be found or located, I undertake to
forward or surrender the same to the Department of Foreign Affairs for appropriate disposal.
I am executing this Affidavit to attest to the truth of the foregoing statements and to
request the issuance of a new passport in lieu of the one which was lost.
AFFIANT FURTHER SAYETH NAUGHT.
IN WITNESS WHEREOF, I have hereunto set my hand this _____ day of _______________.
20___ at _________________________.

ROMMEL D. VILLAMOR

SUBSCRIBED AND SWORN to before me, this ____ day of ______________, 20___ in
_______________________, with affiant exhibiting his Identification Card.
_______________________________________.

Doc. No. : ________;

Page No. : ________;
Book No. : ________;
Series of 20___.