REPUBLIC OF THE  PHILIPPINES )

Province/City__________________  ) SS.

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;
Example:

“3.     THAT I exerted diligence efforts to locate my wallet or identify the

culprit but to no avail and I therefore considered the same as lost and
cannot be found;
4.       THAT I am executing this Affidavit to attest to the truth of the foregoing
facts and to use the same for whatever legal purpose it may serve.

IN WITNESS WHEREOF, I hereunto affix my signature this _______________ 

at __________________.

__________(name)________
Affiant

SUBSCRIBED AND SWORN to before me this _______________ at

__________________, Affiant exhibiting to me his Community Tax Certificate
bearing No. ________________ issued at _________________ on
___________________________.
Doc No. ________;

Page No. _______ ;

Book No. _______;

Series of 2005.