Republic of the Philippines) ____________

PASAY CITY METRO MANILA ) S.S.

AFFIDAVIT OF LOSS OF ORIGINAL DTI APPLICATION FORM

KNOW ALL MEN BY THESE PRESENTS:

I, MARGIECEL ACORDA NUNEZ of legal age, Filipino, married, and a

resident of U-CS5 SOMERSET CONDO. 1809 LEVERIZA ST PASAY CITY,
after having been sworn in accordance with law, hereby deposes and states the
following:

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

document: ORIGINAL DTI APPLICATION FORM

2. I have recently discovered the said item/s is/are 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.

Affiant (Signature over Printed Name)

Competent Evidence of Identity
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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