REPUBLIC OF THE PHILIPPINES NOT FOR SALE

DEPARTMENT OF FOREIGN AFFAIRS

AFFIDAVIT OF LOSS

DATE
Foreign Service Post: (Ex. January 01, 2012)

AFFIDAVIT OF LOSS

I, , Filipino citizen, of legal age, presently residing at

after having been duly sworn to inaccordance with the law, do hereby depose and say:

1. That I lost my Philippine passport numbered

issued in on ;

2. That I discovered the loss on while I was

3. That I exerted diligent effort in locating the said lost passport, but to no avail;

4. That I am executing this affidavit to request the Philippine Embassy to issue a

replacement passport/ travel document in my favor, and;

5. That I attest to the veracity of the foregoing information.

IN WITNESS WHEREOF, I hereby affix my signature this day of

in the year in the .

Signature of Affiant over Printed Name

PHILIPPINE EMBASSY )
CONSULAR SECTION ) S.S.
__________________ )

SUBSCRIBED AND SWORN to before me this day of in the year

at the affiant having exhibited to me his/her passport no.

issued in on and valid until .

Doc. No.: _______________________

Service No.: _____________________
O.R. No.:________________________
Fee Paid: _______________________