Affidavit of Loss Form
FOREIGN SERVICE OF THE PHILIPPINES)
EMBASSY OF THE PHILIPPINES ) S. S.
CONSULAR SECTION, KUALA LUMPUR )
AFFIDAVIT OF LOSS
I, ____________________________________________ of legal age, Filipino citizen, married/single with residence and postal address at
______________________________________________________________________
After having been sworn to in accordance with law, do hereby depose and state the following:
That I am a holder of Philippine Passport No. ____________________________ issued on ___________________ 20____ by the ______________________________
____________________________ in ______________________________________ ;
That the circumstances surrounding the loss of my passport follows:
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That I execute this affidavit for the purpose of giving true and correct statement surrounding the loss of my passport;
That further affiant sayeth naught.
IN WITNESS WHEREOF, I have hereunto affixed my signature this __________
Day of ________________ 2007 at the Philippine Embassy in Kuala Lumpur, Malaysia
_____________________
(Affiant)
SUBSCRIBED AND SWORN to before me this ____________ day of ______________
2007 at Kuala Lumpur, Affiant exhibiting to me photocopy of his/her Passport
No. _______________ issued on _____________________ 20 ____ at ____________
_________________________________.
____________________
Consular Officer
