REPUBLIC OF THE PHILIPPINES)

CITY OF ) S.S.
x-----------------------------------------x

AFFIDAVIT OF LOSS
I, _____, of legal age, Filipino, single and a resident of Barangay ______,
Philippines after having been duly sworn to in accordance with law, depose and
state THAT:

1. I was issued a ______ by the _______;

2. That sometime in ______, said ID was misplaced and got lost;

3. Efforts were exerted to locate said ID, but in spite of diligent search, it could not be
found and the same is now beyond recovery;

4. As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
facts and for the issuance of a New _____ID in lieu of the one that was lost;

IN WITNESS WHEREOF, I have hereunto set my hand this ________ in

_____, Philippines.

_________

SUBCRIBED AND SWORN TO before me this _____, 2019 in _____, Philippines, affiant
exhibiting to me her competent evidence of identity by way of ______ with ID No.
_____ issued at _______

Doc. No. _____;

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