Republic of the Philippines )

Baguio City ) SS.

AFFIDAVIT OF LOSS
I, LEAH QUINTO ROSARIO, of legal age, married, Filipino Citizen with
residence and postal address at 16 Ambiong Road, Aurora Hill, Baguio City,
Philippines, after having been duly sworn to in accordance with law do hereby,
depose and say:

1. That I am a holder of a PHILIPPINE PASSPORT;

2. That on January 1, 2017 my Philippine Passport was lost. I boarded a

UV express from La Union going here to Baguio City at around 3:00
oclock in the afternoon. Upon arrival here in the City, I found out
that my luggage containing my Philippine Passport was missing;

3. That I exerted effort to locate the said passport but it turned futile and
even reported to the PNP of La Union. I believed that the dispatcher of
the terminal misplaced my luggage. The management of the terminal
of the UV Express Van exerted efforts to locate the said luggage but as
of this date there is no development, hence, the passport is
considered forever lost and beyond recovery;

4. That the said Philippine Passport was never given nor pledged to
anyone for any purpose whatsoever, nor it was taken or confiscated
by the authorities for any violation of the law by the Philippine
Government; and

5. That I am executing this affidavit to attest to the veracity and

truthfulness of my foregoing statements and to request for the
issuance of a new PHILIPPINE PASSPORT, in lieu to the lost one and
for all legal intents and purposes it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this 14 th day of

January, 2017, at Baguio City, Philippines.

LEAH QUINTO ROSARIO

AFFIANT
BIR TIN No. 469-538-484
Issued On: May 28, 2015

SUBSCRIBED AND SWORN TO before me this 14th day of January, 2017

at Baguio City, Philippines. Affiant personally appeared before me and to be the
same person who executed this instrument freely and willingly.

Doc. No. 279;

Page No. 56;
Book No. XX;
Series of 2017.