Republic of the Philippines)

Baguio City……………………) S.S.

AFFIDAVIT OF LOSS
I, WILNA LUMPIAS PATON-GAY, of legal age, widow, Filipino Citizen and presently
residing at #30 Purok 3, North Sanitary Camp, Sanitary Camp, Baguio City, Philippines
after having been duly sworn to in accordance with law do hereby depose and say that:

1. I was issued a PHILIPPINE PASSPORT by the Department of Foreign Affairs (DFA),

San Fernando, La Union issued sometime in 2004-2005;

2. I kept my aforesaid PHILIPPINE PASSPORT in an envelope at our residence at North

Sanitary Camp, Sanitary Camp, Baguio City;

3. Last week, when I intend to renew my expired PHILIPPINE PASSPORT, but could
not locate the said passport. I asked my son who is living with me if he had seen it
but he answered me in negative. We had conducted multiple general cleaning at our
house and I suspected that we might have thrown away the envelope where I kept my
passport, maybe we thought that it is a trash;

4. I exerted diligent effort to locate the said PHILIPPINE PASSPORT but the same could
no longer be found and hence, considered forever lost;

5. Said PHILIPPINE PASSPORT was never given nor pledged to anyone for any
purpose whatsoever, nor was it taken or confiscated by the authorities for any
violation of the law particularly the Passport Law;

6. I am executing this affidavit to attest to the veracity and truthfulness of my foregoing

statements and for the purpose of securing a new PHILIPPINE PASSPORT in lieu of
the lost one and for other lawful intents and purposes it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this 22nd day of January,
2018 at Baguio City, Philippines.

WILNA LUMPIAS PATON-GAY

Affiant
Voter’s ID No.: 1102-0575A-K2259WLP2000-2

SUBSCRIBED AND SWORN TO before me this 22nd day of January, 2018 at Baguio
City, Philippines. Affiant personally appeared before me and to be the same person who
executed this instrument as her free act and deed.

MODESTO T. ANDONG
Notary Public
Comm. No. 39-NC-18-R/Until: December 31, 2019
PTR No. 3397734/12-13-2017/BC
IBP No. 1083758/12-13-2017
Baguio-Benguet Chapter
Roll No. 31289/5-15-81/Manila
Doc. No. 100; MCLE COMPLIANCE No. VI-0000192/June 14, 2016
Page No. 021; BIR TIN No. 121-017-652
Book No. XXVIII; No. 19, 2nd Floor Old Market Bldg.,
Series of 2018. Magsaysay Ave., Baguio City, Philippines

Affidavit Loss
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