REPUBLIC OF THE PHILIPPINES)
ANTIPOLO CITY )S.S.
AFFIDAVIT OF LOSS
I, CHRISTOPHER ALLAN ZAMORA USON, of legal age, Filipino, single and resident of Blk
4 Lot 12, Phase 3-A, Bagong Nayon II, Brgy. San Isidro, Antipolo City, Rizal, Philippines, after
having duly sworn to in accordance with law hereby depose and state:
1. That I am a holder of a Philippine Passport issued by the Department of Foreign
Affairs (DFA) , which was in my custody for safekeeping;
2. I hereby declare that I have misplaced my passport and have been unable to locate it
despite diligent efforts;
3. That then said passport has not been encumbered, sold pledge, assigned, alienated.
Transferred, donated, or given as collateral for any debt or obligation to or in favor
of any person or entity;
4. That I understand that my declaration of the abovementioned passport as lost shall
be construed as satisfactory proof that the Passport was lost, in compliance with the
section 15 of R.A. 8239 of the Philippine Passport Act of 1996;
5. That I further understand that the said passport will be immediately deemed
cancelled and may no longer be used for travel or other purposes. As such, in case,
the said passport is found or retrieved, I will immediately surrender it to the
Department of Foreign Affairs (DFA);
6. I am executing this affidavit of loss to attest to the truth of the foregoing fact and for
reissuance/renewal of my Philippine Passport and for whatever legal purpose this
may serve;
7. As such, I am executing this affidavit to attest the foregoing facts and to support the
renewal application for the issuance of a new one in lieu of the one which was lost.
AFFIANT FURTHER SAYETH NAUGHT.
IN WITNESS WHEREOF, I have hereunto signed this affidavit this 22 nd day of November
2024 in Antipolo City, Rizal, Philippines.
CHRISTOPHER ALLAN ZAMORA USON
Affiant
SUBSCRIBED AND SWORN to before me this 22 nd day of November 2024in Antipolo City,
Rizal, Philippines.
Doc. No. 196
Page No. 42
Book No. 27
Series of 2024
