REPUBLIC OF THE PHILIPPINES }

TABUK CITY, KALINGA } SS.

AFFIDAVIT OF LOSS

I, JUAN DELA CRUZ, of legal age, married, Filipino and a resident of

Purok Dato, Bulanao Norte, Tabuk City, Kalinga after having been sworn in
accordance with law hereby depose and state:

1. That I am a holder of UMID No. _______ ;

2. That sometime around June 2019 while I was travelling to Manila, I

noticed that the said ID was missing;

3. That despite diligent search and efforts to locate the said passport I could
not find it such that I now believe that it is now lost beyond recovery;

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

foregoing and to support my application for the issuance of a new
UMID card and for other legal purposes.

IN WITNESS WHEREOF, I have hereunto affixed my signature this 22nd

day of August 2019 in Tabuk City, Kalinga.

JUAN DELA CRUZ

Affiant

SUBSCRIBED AND SWORN to before me this 22nd day of August,

2019 at Tabuk City, Kalinga affiant exhibiting to me her competent
evidence of identity by way of his Tin No. _______ issued on Nov. 29
1991.

NOTARY PUBLIC

Doc. No._____
Page No._____
Book No._____
Series of 2019.