AFFIDAVIT OF LOSS OF PASSPORT
I, __________________________________________, of legal age, Filipino, with
present address at ___________________________________________, Taiwan, after having
been sworn in accordance with law, hereby depose and state that:
1. My personal circumstances are as follows:
DATE AND PLACE OF BIRTH: _______________________________________
SEX: ☐Male ☐Female
CIVIL STATUS: ☐Single ☐Married
NAME OF SPOUSE: _______________________________________________
PHILIPPINE ADDRESS: ____________________________________________
2. I am holder of a Philippine Passport No. ______________ issued on
____________________________ at _____________________________;
3. Sometime in _________________________, I discovered that my said passport
was missing.
4. To my knowledge, my passport was lost when (English or Tagalog):
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________;
5. I took great pains to look for the said passport but to no avail and is now beyond
recovery.
6. I reported the loss of the said passport to the proper authorities of Taiwan. Copy of
the Report of Lost/ Stolen Passport is hereby attached as “Annex A”; and
7. I am executing this Affidavit to attest and affirm to the truth of the foregoing
statement and to support my application for: ☐New Passport ☐Travel Document.
IN WITNESS WHEREOF, I hereby affix my signature this ____________________ in
Taipei City, Taiwan.
___________________________
(Printed Name)
Affiant
MANILA ECONOMIC AND CULTURAL OFFICE
SUBSCRIBED and SWORN TO before me this ________________, at __________, Taiwan
by ___________________________________, who is known to me by competent evidence of
identity consisting of her/his ________________________ with No. __________________,
issued by ___________________________ on ________________ and valid until
____________________.
WITNESS MY HAND AND SEAL of the Manila Economic and Cultural Office on the date
and place above-mentioned.
Series of 20 __________
Service No.___________
Fee Paid-NT$_________
M.R/P.R. No._________
Upon request and authority of the
Department of Foreign Affairs
Republic of the Philippines