Republic of the Philippines)

________________------------------)S.S.

AFFIDAVIT OF LOSS

I, ________________, of legal age, Filipino, _________, and a resident

of _________, Philippines, after having duly sworn to in accordance with law,
hereby depose and state:

1. That I am the _____________, bearing No.

________________issued by _______________ (A copy of which is attached
herein as Annex “A”).

2. ________________

3. That sometime in ____________, I realized the Passport was

misplaced or lost _______

4. That I, together with my family, searched for it in the aforesaid

steel cabinet and in our entire house but it could no longer be found;

5. That my family and I diligently exerted efforts to locate my son’s

Philippine Passport;

6. That in spite of diligent search, deemed lost and at a point of

beyond recovery;

7. That said passports has not been encumbered, sold, pledged,

assigned, alienated, transferred, donated, or given as a collateral for any debt or
obligation to or in favor of any person or entity;

8. That I further understand that said passport will be immediately

deemed cancelled and may no longer be used for travel or other purposes. As
such, in case such passport is found or retrieved, undersigned will immediately
surrender it to the DFA;

9. That I am executing this affidavit to attest to the veracity of the

foregoing facts and for whatever legal purpose it may serve under the law.

IN WITNESS WHEREOF, I have hereto set my hand _____________

in the ________________, Philippines.
_______________
Affiant