REPUBLIC OF THE PHILIPPINES )

_____________________________ ) SS.

AFFIDAVIT OF LOSS OF IDENTIFICATION CARD

I, _______________(name of affiant)_____________, Filipino, of

legal age, single/married to ____________________________(name
of spouse)__________________, and a resident of
____________________(address of affiant)______________, 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 ID number _____(ID number)_____ issued by
[Name of School]/[Name of Company];

2. That I used to put said ID Card in my ID necklace and hang

it on my neck;

3. {When it probably got loss} That sometime on ____(date of

loss)____, when I arrived home from work, I discovered that
my [school]/[company] ID card including my ID necklace was
no longer hanging on my neck;

4. {Where it probably got loss} That

________________________________________;

5. {How it probably got lost} That

__________________________________________;

6. That diligent effort to locate and search in places where I

have been on that day, said ID was nowhere to be found;

7. That said school/company ID card was not confiscated by

the authorities of [school]/[company] by any reason. Neither I
violated any [school]/[company] rules and regulations;

8. That I am executing this affidavit to attest to the truth of the

foregoing facts and to request for a replacement of said
school/company ID card from [school]/[company name].

IN WITNESS WHEREOF, I have hereunto affixed my signature this

____th day of ____________ 20___ at _______________,
Philippines.
_________________________________
(Signature of Affiant over Printed Name)

SUBSCRIBED AND SWORN TO BEFORE ME, a notary public in and for

_________(City/Province)____________ this ____th day of ____________
20___. Affiant personally came and appeared with _____________(Competent
Evidence of Identity)______ issued by the _________(Government
Agency)______ on ___(date)__ at ________(place)_________, bearing his
photograph and signature, known to me as the same person who personally
signed the foregoing instrument before me and avowed under penalty of law to
the whole truth of the contents of said instrument.

Atty _______________________________________
Notary Public
Doc. No. ____ Commission Serial No. __________________
Page No. ____ Notary Public for _______(Province/City)_____
Book No. ____ Until December 31, 20__
Series of 20__ Office: ______________(address)__________
Roll No. __________
IBP Lifetime Roll No. ________; __/__/__ ; (Province)
PTR No. _________ ; __/__/__ ; _(Province)_
MCLE Compliance Cert. No. __________; __/__/__
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