REPUBLIC OF THE PHILIPPINES )

MUNTINLUPA CITY )S.S.

METRO MANILA )

AFFIDAVIT OF LOSS
I, ______________________, of legal age, Filipino, married with residence and postal
address at ____________________________________, after being duly sworn to in accordance
with law hereby depose and say:

1. That I am the holder/owner of ____________________________ bearing No.

________________;

2. That I use to keep the said ____________________________in my wallet for

convenience and safety purposes;

3. That sometime on ___________________, my said _______________________ was

already lost/missing and could have been misplaced/left somewhere for unknown
reason/s;

4. That despite diligent effort to locate said ____________________________all effort

proved futile and the same could no longer be found;

5. That I believe it is now beyond recovery;

6. That I am executing this affidavit to attest to the truth of the foregoing facts not
intended for any fraudulent purpose/s but to report the loss and for all legal intents
and purposes it may serve.

IN WITNESS WHEREOF, I am affixing my signature this ______________ at

Muntinlupa City, Philippines.

______________________
Affiant
___________ ID No. ___________
____________ City

SUBSCRIBED AND SWORN to before me in the date and place abovementioned.

Affiant exhibited me her Competent Evidence of Identity abovementioned.

NOTARY PUBLIC
Doc. No. ____;
Page No. ____;
Book No. ____;
Series of 2017.