AFFIDAVIT OF LOSS OF IDENTIFICATION CARD

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 by________________________;

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
____________, Philippines.

_________________________________
(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.

Notary Public

Doc. No. ........;

Page No. .......;
Book No. .......;
Series of 2011.