AFFIDAVIT OF LOSS

I, ________(name)_______, of legal age and residing/with address at

_________________________________________, under oath, state:

1. THAT on ______(date)_____ at _________(place)_________ while _________(describe how

loss occurred)___________;

Example:

“1. THAT on 28 February 2005 while riding on a jeepney on my way home, my wallet was pick-
pocketed without my knowledge; “

2. THAT ___________________(describe the particulars of what was lost)_____;

Example:

“2. THAT my wallet contained my school ID, my Driver’s License and some money bills;

3. THAT I exerted diligent efforts to locate _____(the thing lost)____ or but to no avail and I
therefore considered the same as lost and can no longer be found;