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REPUBLIC OF THE PHILIPPINES)
_____________________________ ) SS.
I, ______________________, Filipino, of legal age, and a resident of ______________________________________, after
having been duly sworn in accordance with law, hereby depose and say:
1. That I am a holder of a school/company identification card bearing serial number____________________ issued
2. That I used to put said identification card in my pouch.
3. That sometime on____________________, when I arrived home from work, I discovered that my school/company ID card
was no longer in my pouch where I used to place it;
4. Despite diligent search and efforts to locate said document, I could not find it.
5. That said school/company ID card was not confiscated by the authorities of company by reason of any violation of company
rules and regulations;
6. That I am executing this affidavit to attest to the truth of the foregoing facts and to request for a replacement of said company
ID card from ___________________________________________.
IN WITNESS WHEREOF, I have hereunto affixed my signature this ____day of ____________ 20___ at ____________,
(Signature of Affiant over Printed Name)
SUBSCRIBED AND SWORN TO before me, a notary public in and for _____________________ this ____ day of
____________ 20___. The affiant, whom I identified through the following competent evidence of identity:_____________,
valid from______ to______ issued by_______________, 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 2011.