REPUBLIC OF THE PHILIPPINES )

CITY OF TABUK ) S.S.

AFFIDAVIT OF LOSS
I, _____ , of legal age, married, Filipino, and presently residing at ___
after having been duly sworn to in accordance with law, hereby depose
and state:

1. That I am the holder and owner of ___ ;

2. That it was issued by ___ on ___ ;

3. That I kept said ID in my wallet but said wallet is missing and all
its contents;

4. That I exerted all efforts to locate it but to no avail;

5. That I am executing this Affidavit to attest to the truth of the

foregoing facts and for whatever legal purpose and intent it may
serve.

Signed on the date and at the place indicated below.

NAME
ID NO, Date issued/validity
Affiant

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 Tabuk City, Kalinga, Philippines.

WITNESS MY HAND AND SEAL.

ATTY. BETHLEHEM G. PANGSIW

NOTARY PUBLIC
Until December 31, 2019
Roll No. 67890; June 2, 2017
PTR No. 1696329; 03-01-2018
IBP O.R. No. 1086650; 03-01-2018; Tabuk City, Kalinga
MCLE No. VI-0027712 issued on July 11, 2019
Email Add: m_pangsiw@yahoo.com/0927326731
Doc. No. ___ ;
Page No. ___ ;
Book No. III ;
Series of 2019.