AFFIDAVIT OF LOSS

I, Ace Bita, of legal age, Filipino, and a resident of Castillo Street, Barangay
BF, Quezon City, after having been duly sworn to in accordance with law, hereby
depose and state that:
1. I am a holder of the following Government Issued Identification Cards:

a.) Unified Multipurpose ID with corresponding number 123456;

b.) PhilHealth Card ID with corresponding number 0132015;
c.) BIR TIN Card with corresponding number 1010658;

2. I keep all the foregoing Identification Cards in my wallet for safe-keeping;

3. In the early morning of 2 January 2012, I fell asleep in the bus I was
riding while commuting to work;

4. However, when I woke up, I suddenly discovered that my wallet was no

longer in my pocket, and has already been stolen or lost;

5. Despite diligent search and efforts to locate my wallet, with all other
documents placed therein, I could no longer find the same, and is
already beyond recovery;

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

facts, and to request for the issuances of replacement identification
cards from their respective government agencies/offices.

IN WITNESS WHEREOF, I have hereunto affixed my signature this

_______________ in Mandaluyong City.

ACE BITA