REPUBLIC OF THE PHILIPPINES)

Province of ______________ ) SS.

Municipality of___________

AFFIDAVIT OF LOSS

I, ______________________________ , of legal age, single, and with address at

_____________________________________________, after having been duly sworn to an
oath in accordance with law do hereby depose and state:

1. THAT, I am a holder of __________________issued by ________________;

2. THAT, I used to put said HDMF Identification card together with my other ID’s
inside my wallet;

3. THAT, sometime on December 28, 2017, I discovered that said HDMF

Identification card was missing and was no longer inside my wallet;

4. THAT, despite diligent efforts to locate said HDMF ID, the same can no longer be
found or retrieved and my searched proved futile;

5. THAT, said HDMF ID card was not confiscated by the authorities or apprehended
for any violation of the law;

6. THAT, I am executing this Affidavit to attest to the truth of the foregoing facts and
to request for its replacement from the HDMF Office.

IN WITNESS WHEREOF, I have hereunto affix my signature this _____ day of February
2018 at Taft, Eastern Samar, Philippines.

Juan de la cruz
Affiant

SUBSCRIBED AND SWORN to before me this ______day of February 2018 at Taft,

Eastern Samar, Philippines, Affiant exhibiting to me his Govt. Issued ID #______________
issued at_________________Philippines.

Doc No. _________

Page No. ________
Book No. ________
Series of 2018