Republic of the Philippines )

City of () ) S.S.

AFFIDAVIT OF LOSS

I, (Name), of legal age and resident of (Address) under oath

declare that:

1. I was issued a (ID type) by (Institution);

2. (Statement of facts)

IN WITNESS WHEREOF, I have signed this document this

(date) in (venue)

(Name)
Affiant

SUBSCRIBED AND SWORN to before me this day of February 2019

at City of Manila, Philippines. Affiant exhibited to me here IBP ID with
Lifetime Membership NO. 7833.

ATTY. JULIAN CRISOSTOMO

Notary Public for Manila
Unit 1, X Building, Manila
Appointment No. 123, Until December 31,
2019
IBP No. 123456; 01/10/10 - Manila
PTR No. 123456; 01/10/10 - Manila
Roll No. 123456 - 4/20/06
MCLE No. I -0234; 09/09/16
MCLE No. II - 0056; 09/09/16
Serial No. Of Commission M-123
Doc. No. 123
Page No. 123
Book No. 123
Series of 2019

Doc. No. 123

Page No. 123
Book No. 123
Series of 2019