Anda di halaman 1dari 1

REPUBLIC OF THE PHILIPPINES

______________________

AFFIDAVIT OF LOSS
KNOWN ALL MEN BY THESE PRESENTS:

I, BENEDICT TOMO SARMOY, of legal age, Filipino, single, and a resident of Brgy.
Alim Hinoba-an Negros Occidental Philippines, after having been sworn in
accordance with law, hereby deposes and states the following:

1, I am holder/ owner of my PHILIPPINE PASSPORT;

2. That while eating lunch at Harrison Plaza Mall, I accidentally left my purse
containing my passport and my wallet,

3. That I have recently discovered that my passport is irretrievable lost and can
no longer be found despite diligent efforts to locate the same;

4. I execute this affidavit to attest to the truth of the foregoing.

Signed on the date and at the place indicated below.

Affiant

(Signature over printed name)

SUBSCRIBED AND SWORN TO before me on the date and at the place indicated
below. The affiant exhibited to me his competent evidence of identity as indicated
above.

Signed this _______________ at _____________, Philippines

WITNESS MY HAND AND SEAL.

Doc. No.
Page No.
Book No.
Series of.