Republic of the Philippines)

City of Manila ) S.S.

AFFIDAVIT OF LOSS

KNOW ALL MEN BY THESE PRESENTS:

I _______________________________ of legal age, Filipino, single/married, and

resident of __________________________, after having been sworn in accordance with
law, hereby deposes and states the following:

1. I am holder/owner/or possessor of the following identification card/document:

____________________________________

2. I have recently discovered the said item/s is/are irretrievably lost and can no
longer be found despite diligent efforts to locate the same;

3. I execute this affidavit to attest to the truth of the foregoing.

Signed on the date at the place indicated below.

Affiant
(Signature over printed name)
Competent evidence of identity
ID:
Issued on:
At:

SUBSCRIBED and SWORN TO before me on the date and at the place indicated
below. The affiant exhibited to me his competent evidence of identity as indicated
below.

Signed this _______________ at ________________, _____________________, Philippines.

WITNESS MY HAND ON SEAL

Notary Public

Doc No.____________;
Page No.___________;
Book No.___________;
Series of ___________;