Republic of the Philippines )

City of Dipolog ) S.S

x------------------------------------x

AFFIDAVIT OF LOSS

I, GEMMA E. SALMORIN, Filipino, of legal age, separated-in-fact and a resident

of Gutalac, Zamboanga del Norte, after having duly sworn in accordance with law, do
hereby depose and state that:

1. That I am the holder of Passport No. EB2572402 issued by Department of

Foreign Affairs (DFA), Zamboanga City, sometime on May 2011;

2. That sometime at about 9:00 am., July 14, 2018 while I was aboard on a
passenger motorcycle travelling from my residence at Sangkol, Dipolog City
going to the City proper in order to withdraw money and upon arrival thereat
I thoroughly search my passport but to my dismay I was not able to retrieved
it despite deligent efforts and I honestly believe it could have fallen either in
the motorcab or somewhere;

3. That I decided to report the incident to the PNP station, Dipolog City to
validate my claim, Photocopy of PNP Incident Report is hereto attached and
marked as Annex “A”;

4. That I am executing this affidavit for the purpose of requesting the DFA,
Zamboanga City, to issue another passport in my behalf in lieu of the lost
one.

IN WITNESS WHEREOF, I have hereunto affixed our hands this____ day of

_______________ at Dipolog City, Philippines.

GEMMA E. SALMORIN

Affiant

SUBSCRIBE AND SWORN TO before me this ______________ at Dipolog City,

Philippines, with affiant exhibiting her COMELEC ID NO. 7223-0044A-
A0784GES20000-4, issued at Gutalac, Zamboanga del Norte.

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Republic of the Philippines )
City of Dipolog ) S.S
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AFFIDAVIT OF LOSS

I, FREDERICK S. CALOG, of legal age, Filipino, married and a resident of

Barangay Alvinda, Mutia, Zamboanga del Norte, after having duly sworn in accordance
with law, do hereby depose and state that:

1. That I am a holder of an Official Receipt from a purchase of a chainsaw in

Oroquieta City in the year 2017 which is more particularly described as
follows:
BRAND SERIAL MACHINE NO.

ZERO70 STEEL S178200084

2. That the said document while in my possession was misplaced and could no
longer ne located inspite of exerting efforts of locating them;

3. That I am executing this affidavit to attest the truth of the foregoing and for
whatever legal purpose it may serve.

AFFIANT FURTHER SAYETH NAUGHT.

IN WITNESS WHEREOF, we have hereunto affixed our hands this____ day of

_______________ at ________________.

FREDERICK S. CALOG
Affiant
Philhealth ID 16-050166521-2

SUBSCRIBE AND SWORN TO before me this August 31, 2018 at Dipolog City.

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