REPUBLIC OF THE PHILIPPINES )
PROVINCE OF AGUSAN DEL SUR )S.S.
X - - - - - - - - - - - - - - - - - - - - - - - -X
A F F I D AV I T OF LOSS
AFFIANT:
NAME: BERNARDINO JR. MONGADO TARAY
(First Name) (Middle Name) (Last Name/Surname)
Date of Birth: September 5, 1985 Place of Birth: Mainit, Surigao Del Norte
Civil Status: Single
Residence: Butuan City, Philippines Cellphone.# : 0930 979 7954
Passport No. : EB0481816 Date of Issue : June 28, 2010
Place of Issue: DFA BUTUAN
after being sworn according to law, depose and say:
1. That I am a Philippine citizen and holder of Philippine passport described above:
2. That recently, I had tried to look for the said passport but the same could not be found;
3. That efforts were exerted to locate the lost passport, but in spite of diligent search, it could
not be found and the same is now beyond recovery.
4. That I need a new passport urgently for my employment application requirements abroad;
5. That in view of the foregoing reason, it is requested that a new passport be issued to the
undersigned, in lieu of the lost passport, subject to compliance with prescribed requirements.
IN WITNESS WHEREOF, I have hereunto affixed my signature this 12 th day of September 2017, at
Prosperidad, Agusan del Sur, Philippines.
BERNARDINO M. TARAY JR.
Affiant
SUBSCRIBED AND SWORN to before me this 12th day of September 2017, at Prosperidad,
Agusan del Sur, Philippines.
Doc. No. :
Book No. : II
Page No. :
Series : 2017
REPUBLIC OF THE PHILIPPINES)
CITY OF _______ )S.S.
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AFFIDAVIT OF LOSS
I, ___________, Filipino, of legal age, single/married and a resident of
__________________________, Philippines, after having duly sworn to in accordance
with law, hereby depose and say that:
1. I am a holder of a student Identification Card issued by
_____________________________ ;
2. I lost said Identification Card on ____________________ and that I exerted all
efforts to locate the same but I could not remember exactly where I placed/left it
and it is considered lost for all legal purposes;
3. Said Identification Card was not confiscated by any officer of the law or the
officers of (name of school) by reason of any violation of any law, ordinance,
presidential decree or rules and regulation of said university; and neither was it
offered as collateral for any loan;
4. I am executing this affidavit to attest to the foregoing facts;
IN WITNESS WHEREOF, I have hereunto set my hand this ______________ in
the City of _____________, Philippines.
________________
Affiant
SUBSCRIBED AND SWORN to before me this _______________ in the City of
__________, Philippines, affiant having exhibited to me his/her community tax
certificate with no. __________________ issued on _________________ at
______________ .
Doc. No. ________;
Page No. ________;
Book No.________;
Series of 2006.
