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REPUBLIC OF THE PHILIPPINES )

CITY OF TAGBILARAN ) S.S.


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AFFIDAVIT OF LOSS

I, GLORIA FLORES VILLOCIDO, of legal age, a resident of Purok 4, Loreto, Cortes,


Bohol, after having been duly sworn in accordance with law hereby depose and state that:

1. I am the owner of a PHILIPPINE PASSPORT;

2. Sometime last October 15, 2013, a 7.2 magnitude earthquake hit Bohol which caused
that destruction of a portion of my house;

3. The said portion was where I stored certain important documents including my Passport,

4. However, despite my utmost diligent effort and meticulous endeavor to recover the same,
I was unable to recover the said Passport which was trapped under the rubble;

5. I am executing this affidavit to attest to the truthfulness of the foregoing and for whatever
purpose it may serve.

IN WITNESS WHEREOF, I have hereunto affixed my signature on this 1st day of October 2019,
at Tagbilaran City.

GLORIA FLORES VILLOCIDO


Pag-IBIG ID No. 1670-0106-7288
Affiant

SUBSCRIBED and SWORN to before me this 1st day of October 2019, at Tagbilaran City. I hereby
certify that I have personally examined the above-named affiant and that I am satisfied that the
foregoing statements were given by him voluntarily and of his own free will.

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