REPUBLIC OF THE PHILIPPINES )

CITY OF MANILA )

AFFIDAVIT OF LOSS

I, ALIPIO F. ANTONIO JR, of legal age, married, Filipino Citizen, and

presently residing at Brgy. San Agustin Victoria Tarlac , after having been duly
sworn to in accordance with law do hereby depose and state:

That I am holder of the following;

1. Security License I.D Card

2. Drivers License
3. Company I.D Card
4. Philhealth I.D Card
5. Pag-ibig I.D Card
6. Tin.# B-I-R I.D Card
7. Comelec I.D Card
8. Police Clearance I.D Card
9. Citi Bank Atm
10. Cibuana I.D Card
11. Mercury Drug I.D Card
12. Jollibee Card
13. Seven Eleven Card
14. PNB Statement Of Account
15. SSS Verification Paper
16. Palawan Express I.D Card

That for causes, reasons and circumstances beyond my control, I lost the
possession of the aforementioned I.D.s last June 15, 2015 on my way to Monumento;

That I exerted diligent efforts to locate the same, but to no avail, hence considered
them lost;

That I am executing this affidavit for the purpose of showing under oath the truth
of the foregoing facts and circumstances;

Further, I am also executing this affidavit for whatever legal purposes this may
serve.

IN WITNESS WHEREOF, I have hereunto set my hand this 16 th day of June

2015 at the City of Manila.

, ALIPIO F. ANTONIO JR

Affiant

SUBSCRIBED AND SWORN TO before me this 16th day of June 2015

in the City of Manila.

Doc. No. _________

Page No.__________
Book No._________
Series of 2015.