Affidavit Of Loss printable pdf download

AFFIDAVIT OF LOSS

I, ______________________________________________, Filipino, of legal age,

single/ married to ________________________________, after having been sworn to in

accordance with law, do hereby depose and say:

That I was born on _____________________ at _____________________,

the legitimate child of __________________________, a citizen of ____________ and

____________________________, a citizen of ______________;

That

my immigration

status

the

United

States

that

and that I arrived in the United States on or about _________________________;

That I have been issued Philippine Passport No. ______________________

at ____________________________ on _______________________:

That the aforesaid passport was lost on _____________________under the

following circumstances; to wit:

_______________________________________________________________________

________________________________________________________________________

_______________________________________________________________________

That the efforts to find the said passport were not successful;

That on _______________________, I reported that said loss to the police

authorities at _____________________________. Attached is a copy of the Police Report

issued by the police authorities of _______________________________;

That I am executing this affidavit of attest the aforementioned facts and in

support of my application for a new passport.

I HEREBY CERTIFY UNDER PENALTY OF LAW TO THE TRUTH AND

CORRECTNESS OF THE ABOVE STATEMENT.

___________________________

Affiant

CONSULATE GENERAL OF THE PHILIPPINES

)

CHICAGO, ILLINOIS

)

Subscribed and sworn to before me this ________ day of ______________

20___ at Chicago, Illinois, U.S.A.

Fee

: ______________

O.R. No.

: _____________

Service No. : _____________

Affidavit Of Loss