Affidavit of Loss - Chicago

AFFIDAVIT OF LOSS
I, ______________________________________________, Filipino, of legal age,
single/ married to ________________________________, after having been sworn to in
accordance with law, do hereby depose and say:
1. That I was born on _____________________ at _____________________,
the legitimate child of __________________________, a citizen of ____________ and
____________________________, a citizen of ______________;
2. That my immigration status in the United States is that of _____________
and that I arrived in the United States on or about _________________________;
3. That I have been issued Philippine Passport No. ______________________
at ____________________________ on _______________________:
4. That the aforesaid passport was lost on _____________________under the
following circumstances; to wit:
_______________________________________________________________________
________________________________________________________________________
_______________________________________________________________________
5. That the efforts to find the said passport were not successful;
6. That on _______________________, I reported that said loss to the police
authorities at _____________________________. Attached is a copy of the Police Report
issued by the police authorities of _______________________________;
7. That I am executing this affidavit of attest the aforementioned facts and in
support of my application for a new passport.
I HEREBY CERTIFY UNDER PENALTY OF LAW TO THE TRUTH AND
CORRECTNESS OF THE ABOVE STATEMENT.
___________________________
Affiant
___________________________
Notary Public
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