REPUBLIC OF THE PHILIPPINES)

QUEZON CITY, METRO MANILA)S.S

AFFIDAVIT OF LOSS

I, ________________________________________, Filipino, of legal age, and a

(NAME)
resident of ______________________________________________, after having been
(ADDRESS)
duly sworn to in accordance with law, do hereby depose and state:

1. I am the holder/owner of
_____________________________________________________;

2. The same Id has always been placed/kept in

__________________________;

3. Please state circumstance as to the loss of said property:

_______________________________________________________________
_______________________________________________________________

4. Earnest and diligent effort was exerted on my part in locating the above
described property, but such proved to be futile and in vain, hence, that the
same has been completely lost and is now beyond recovery;

5. I am executing this affidavit to attest to the truthfulness of the foregoing

facts and for whatever legal purpose it may best serve.
day of
IN WITNESS WHEREOF, I have hereunto set my hand this ____
_________, 2019 at Quezon City.

_________________________________
Affiant

SUBSCRIBED AND SWORN to before me this _____ day of ____________,

2019 at Quezon City, affiant exhibiting to me his/her
___________________________________________ as his/her competent evidence of
identity.

Doc. No. _____

Page No. _____
Book No. _____
Series of 2019