REPUBLIC OF THE PHILIPPINES)

Province of ____________________) S.S.

City/Municipality of _____________)
x-----------------------x

AFFIDAVIT OF LOSS

I, ---_________________________,, Filipino, of legal age, single/married, and a

resident of ---_________________________,, Philippines, after being duly sworn to in
accordance with law, hereby depose and state:
1 That I am a holder of a FOOD AND MEDICINE PASS (FM Pass)
issued by the City Government of Davao sometime on April 2000.
2 That the implementation of the use of FM Pass was lifted on August
3, 2020.
3 That the City Government of Davao reimposed the use of FM Pass
on November 17, 2020.
4 That due to the significant period of time wherein the FM Pass has
not been used, the same has been misplaced and could no longer be
found;
5 That despite diligent search and efforts to locate the said FM Pass, I
could not find them such that I now believe that they are now lost
beyond recovery;
6 As such, I am executing this Affidavit of Loss to attest to the truth of
the foregoing and for whatever legal purpose this may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this _____________ at

_____________, Philippines.

---_________________________,
AFFIANT

SUBSCRIBED AND SWORN TO before me, a notary public in and for

_____________________ this _______ day of ___________ 2020. The affiant whom I
identified through the following competent evidence of identity ________________ issued
by _______________, personally signed the foregoing instrument before me and avowed
under penalty

Doc No. _____

Page No. _____
Book No. _____
Series of 2020