Republic of the Philippines)City of Zamboanga . . . . . )s.s.x- - - - - - - - - - - - - - - - -x

AFFIDAVIT OF LOSS

I, ABDULKARIM ALLI ANTAM, of legal age, Filipino and a resident of Calarian, Zamboanga City, Philippines, after having been sworn, despose and state:

1. That I a holder of a PHILIPPINE PASSPORT issued by the Department of Affairs;

2. That I usually kept my PASSPORT at a certain drawer situated in one of the rooms of my house;

3. That sometime on September 21, 2014, when I was searching for the aforesaid passport, I was surprised to discover that the same was missing in the place where I kept the same and I cannot recall whether I misplaced it or fell somewhere else;

4. That diligent effort in search of the said PASSPORT had been exerted but the same proved futile hence, I now consider the said passport a complete loss or beyond recovery;

5. That said PASSPORT was not confiscated by any government agency nor used as consideration for any unlawful purpose/s;

6. That I execute this affidavit to attest to the truthfulness of the foregoing statements and to request the Department of Foreign Affairs - Zamboanga City to issue me another passport in lieu of the lost one and for whatever legal purpose/s this may serve under the law.

IN WITNESS WHEREOF, I have hereunto set my hand and affixed my signature this 29th day of June 2015, at Zamboanga City, Philippines.

ABDULKARIM ALLI ANTAM Affiant

SUBSCRIBED AND SWORN TO BEFORE ME, a notary public in and for City of Zamboanga this 29TH DAY OF June, 2015. Affiant personally came and appeared with PROFESSIONAL DRIVER’S LICENSE ID bearing No. JO4-97-061550, known to me and to me known to be as the same person who personally signed the foregoing instrument before me and avowed under penalty of law to the whole truth of the contents of said instrument.

Doc. No. ____;Page No. ____; Book No. ____;Series of 2015