Affidavit Of Loss
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1REPUBLIC 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: _______________________
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