REPUBLIC OF THE PHILIPPINES )

QUEZON CITY, METRO MANILA ) S. S

AFFIDAVIT OF LOSS
I, ALIPIO BENCITO CLEOFE, of legal age, Filipino, widower and presently
residing at B58 L21, Brgy. Santo Cristo, Dasmariñas, Cavite, after being duly sworn to in
accordance with law hereby depose and say;

1. That on January 5, 2016 at around 4:00 in the morning, affiant boarded the
bus from Cavite and alighted in Baclaran and went to Veterans Memorial
Medical Center (VMMC) in Quezon City. Upon reaching VMMC, it was then
that he realized that his Identification Card from Veterans Memorial Medical
Center was already missing;

2. That affiant last saw his Identification Card from Veterans Memorial Medical
Center which was inside his bag last December 10, 2015 when he went to
VMMC to get some medicines;

3. That herein affiant exerted his utmost effort in retrieving said lost property
but said efforts were for naught;

4. That affiant is executing this affidavit to attest to the truth of the said
allegations and for whatever legal purpose it may serve.

FURTHER AFFIANT SAYETH NAUGHT:

IN WITNESS WHEREOF, I have hereunto affix my signature this 6 th day of

January 2016, at Quezon City, Metro Manila.

ALIPIO BENCITO CLEOFE

Affiant

SUBSCRIBED AND SWORN to before me this ____ day of January 2016 at

Quezon City, Metro Manila. Affiant exhibited to me his Identification Card from the
Armed Forces of the Philippines (AFP) with Number R09-E-97924, bearing his
photograph and signature.

Doc. No. _______

Page No. _______
 2
Book No. _______
Series of 2016.