REPUBLIC OF THE PHILIPPINES )

ILOILO CITY ) SS.

AFFIDAVIT OF LOSS


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 _____________________________ issued by
___________________________.
2. That I used to put said identification card inside my wallet;
3. That sometime on _______________________, when I arrived home, I discovered that my
___________________________________ was no longer in my wallet where I used to place it;
4. That diligent effort to locate the same had proved futile;
5. That said ID card was not confiscated by the authorities or used in violation of the law;
6. That I am executing this affidavit to attest to the truth of the foregoing facts and to request
for a replacement of said __________________________________.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ____day of ____________
2014 at Iloilo City, Philippines.


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.


Notary Public








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