REPUBLIC OF THE PHILIPPINES)

CITY OF MANILA ) S.S.

AFFIDAVIT OF LOSS

I, NARCISO SILORIO BASA, of legal age, Filipino Citizen, married

and with residence address at Lot 4, Block 5, St. Joseph Street, Villa Priscilla
Subdivision, Barangay Cut-Cot, Pulilan, Bulacan, after having been duly
sworn to in accordance with law, do hereby depose and state:

1. That I am a Holder of a Claim Stub issued by the

Department of Foreign Affairs of November 19, 2016 for the
purpose of claiming my renewed Philippine Passport;

2. That sometime on November 19, 2016, said Claim Stub was

misplaced at my said residence address;

3. That despite diligent efforts to locate said claim stub, the

same proved futile and useless as I never found said stub
again;

4. I execute this Affidavit to attest to the truth of the foregoing

facts, for the purpose of claiming my renewed Philippine
Passport and for whatever legal intents and purposes this
may serve.

IN WITNESS WHEREOF, I have hereunto affixed my signature this 1 st

day of December 2016 at the City of Manila, Philippines.

NARCISO SILORIO BASA

-Affiant-

SUBSCRIBED AND SWORN to before me this 1st day of

December 2016, Affiant, exhibiting to me his Driver’s License No. N04-
86-036789 with expiry date: 2018-01-10.

NOTARY PUBLIC
Doc. No.
Page No.
Book No.
Series of 2016.