Republic of the Philippines )

Province of Zamboanga del Norte) S.S.

City of Dipolog )

AFFIDAVIT OF LOSS

KNOW ALL MEN BY THESE PRESENTS:

I, ______________________________________ of legal age, Filipino, married,

and a resident of ________________________________________________, after
having been sworn in accordance with law, hereby deposes and states the following:

1. I am holder/owner/ or possessor of the following employee identification card

of _______________________________________.,

2. I have recently discovered the said ID is irretrievably lost and can no longer be
found despite diligent efforts to locate the same;

3. I execute this affidavit to attest to the truth of the foregoing.

Signed on the date and at the place indicated below.

(name)
ID: ______________
issued on: ______________
at: ____________________

SUBSCRIBED and SWORN TO before me on the date and at the place indicated
below. The affiant exhibited to me his competent evidence of identity as indicated above.

Signed this ______________at ________________, ______________________,

Philippines.

WITNESS MY HAND AND SEAL.

Notary Public

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