REPUBLIC OF THE PHILIPPINES )

PROVINCE OF _______________________ )
CITY/MUNICIPALITY OF _______________ ) S.S.
x- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - x

AFFIDAVIT OF LOSS

I, _____________________________, Filipino, of legal age, married, and currently

residing at _________________________________, under oath hereby depose and state that:
1.  I am the owner of a ____________________ issued by
_____________________________ for _______________________________________;
2. The said _____________________, while in my possession, was LOST AND
MISPLACED sometime on ___________________________ and could no longer be located in
spite of diligent efforts to locate it;
3. I shall assume responsibility or liability if in any event I will use this document for
whatever illicit transactions;
4. I am executing this affidavit to attest to the veracity of my statements and to support
my request for ___________________________________________.
5. That this Affidavit is done in good faith and for all legal intents and purposes.

FURTHER AFFIANT SAYETH NAUGHT.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ______________
2018 in _____________________________, Philippines.

___________________________________
Affiant

JURAT

SUBSCRIBED AND SWORN TO BEFORE ME, Affiant ____________________________

personally appeared and exhibited to me his/her CTC/Valid ID No. ___________________ issued
by ______________________________________.

WITNESS MY HAND AND NOTARIAL SEAL this ___________________ 2018 at

________________________________, Philippines.

Doc. No. _____;

Page No._____;
Book No._____;
Series of 2018.