Republic of the Philippines)

Baguio City……………………) S.S.

AFFIDAVIT OF LOSS
I, CLEMENTE ORTIZ BLANCO, of legal age, married, Filipino Citizen and presently
residing at #16 Balacbac Rd., Santo Tomas Proper, Baguio City, Philippines after having
been duly sworn to in accordance with law do hereby depose and say that:

1. I was issued a PHILIPPINE PASSPORT by the Department of Foreign Affairs (DFA),

San Fernando sometime on July, 2006;

2. I kept my aforesaid PHILIPPINE PASSPORT in an envelope at our old residence at

Santo Tomas Proper, Baguio City and sometime on the year 2016 we transferred to
another house;

3. Last week, when I intend to use my PHILIPPINE PASSPORT I went home to look for
it but could not locate the said PASSPORT. I asked the people in our house if they
have seen my PASSPORT but they told me they did not. I suspected that the
envelope where I kept my passport might have been misplaced while we were
transferring or thrown away being mistaken as a discarded envelope;

4. I exerted diligent effort to locate the said PHILIPPINE PASSPORT but the same could
no longer be found and hence, considered forever lost;

5. Said PHILIPPINE PASSPORT was never given nor pledged to anyone for any
purpose whatsoever, nor was it taken or confiscated by the authorities for any
violation of the law particularly the Passport Law;

6. I am executing this affidavit to attest to the veracity and truthfulness of my foregoing

statements and for other lawful intents and purposes it may serve and that I will be
very careful in safekeeping the NEW PHILIPPINE PASSPORT which will be issued to
me.

IN WITNESS WHEREOF, I have hereunto set my hand this 30th day of December,
2017 at Baguio City, Philippines.

CLEMENTE ORTIZ BLANCO

Affiant
Voter’s ID No. 1102-0652A-L2466COB10000-2

SUBSCRIBED AND SWORN TO before me this 30th day of December, 2017 at Baguio
City, Philippines. Affiant personally appeared before me and to be the same person who
executed this instrument as his free act and deed.

MODESTO T. ANDONG
Notary Public
Commission No. 35-NC-16-R/Until: December 31, 2017
PTR No. 2945281/01-05-2017/Baguio City
IBP No. 1056844/01-05-2017/Baguio-Benguet Chapter
Roll No. 31289/5-15-81/Manila
Doc. No. 144; MCLE COMPLIANCE No. VI-0000192/June 14, 2016
Page No. 29; BIR TIN No. 121-017-652
Book No. XXVII; No. 19, 2nd Floor Old Market Bldg.,
Series of 2017. Magsaysay Ave., Baguio City, Philippines

Affidavit Loss
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