Affidavit of Loss of Philippine Passport

AFFIDAVIT OF LOSS OF PHILIPPINE PASSPORT

I, _______________________________________________________________________, a Philippine citizen, of legal age,  single /  married, after having been sworn to in accordance with law, do hereby depose and say, that: 1. The following are my complete contact details: ddress in !rance or "onaco

Telephone #$mber%s&

'. The following are my T()* #+ (* birth and personal data: ast #ame !irst #ame "iddle #ame +ate of -irth Place of -irth . I am the holder of a Philippine passport with the following data: Passport Passport #$mber +ate of Iss$e +ate of *piry Place of Iss$e

0. The following are the information abo$t my trip to !rance: Place of rigin

+ate of +epart$re from Place of rigin

#ame of irline

+estination

Places of Transit

+ate of rrival in !rance

Place of *ntry in !rance

#ame of Travelling 2ompanion

(elationship to Travelling 2ompanion

3. The aforementioned Philippine passport was lost on ________________________________ at approimately ______ am/pm, d$e to the following circ$mstances: (please narrate the circumstances leading to the loss of your passport)  ____________________________________________________________________________________________________   ____________________________________________________________________________________________________   ____________________________________________________________________________________________________   ____________________________________________________________________________________________________   ___________________________________________________________________________________________________4 5. 6aid passport was lost d$e to the foregoing circ$mstances and not thro$gh negligence, with willf$l intent or for any $lterior motive on my part4 7. *rnest efforts have been eerted to recover my passport, b$t to no avail4 and 8. I am eec$ting this ffidavit in s$pport of my application for a new Philippine passport and for whatever legal p$rpose and intent it may serve. I# 9IT#*66 9*(*!, I hereby sign this ffidavit on ____________________________ in ________________________.

 ___________________________________________  Printed #ame and 6ignat$re *"-66; ! T* PIIPPI#*6 2#6)( 6*2TI# P(I6, !(#2*

& & 66 &

6)-62(I-*+ #+ 69(# T before me on ______________________ _________________________________a ___________att the *mbassy of the Philippines, Paris, !rance.

+oc: P______