AFFIDAVIT OF LOSS OF PASSPORT

I, ____________________________________________, Filipino citizen, of legal age,

single / married / widow(er) / divorced / annulled, and presently residing at _________________

________________________________________________ after having been duly sworn to in

accordance with law, hereby depose and state:

1. That the undersigned was issued a Philippine Passport by the Department of Foreign

Affairs (DFA) in Manila/Consular Office/ Philippine Embassy/Consulate with the

following details: Philippine Passport No: _____________________, Date of Issue:

___________________, and Issuing Authority: ______________________.

2. That the said passport was lost on ______________________ (Date) under the

following circumstances:

___________________________________________________________________

3. That the undersigned exerted all efforts possible to locate the said passport but to no

avail;

4. That the undersigned fully understands that the said passport is automatically deemed

cancelled upon declaration of loss and that if found, it can no longer be used;

5. That the undersigned is executing this Affidavit of Loss in connection with his/her

present application for a new Philippine passport; and

That further Affiant/s sayeth none.

IN WITNESS WHEREOF, I have hereunto affix my signature this ____ day of

___________________ 20____ at _____________________________.

_________________________________

AFFIANT’S SIGNATURE OVER PRINTED NAME

SUBSCRIBED AND SWORN TO before me this ____ day of _________________ 20___

at _______________________________.

_________________________________

ADMINISTERING OFFICER / NOTARY PUBLIC