Republic of the Philippines )

Cainta, Rizal ) SS.

AFFIDAVIT OF LOSS
I, _______________, Filipino, of legal age, single, and a resident of
_______________ under oath do hereby depose and state, that:

I hold documents duly issued by the _______________, to wit:

a. Mayor’s Permit; and

b. Health Permit.

It so happened, however, that my bag was stolen along with said Mayor’s and
Health Permits which were contained therein and is nowhere to be found;

I declare under penalties of perjury that this affidavit has been made in good
faith verified by me and to the best knowledge and belief is true and correct;

Earnest efforts were exerted on my part to retrieve the same but to no avail;

This affidavit is being executed to attest to the veracity of the foregoing

instrument in order to establish the existence of the above-mentioned Permits and the
facts of its subsequent loss for purposes not contrary to law, morals, good custom and
public policy.

IN WITNESS WHEREOF, I have hereunto set my hand this 27 th day of April 2016
at Cainta, Rizal.

_______________
Affiant

SUBSCRIBED AND SWORN TO before me on the date and at the place above
written, affiant exhibiting to me his TIN I.D. “_______________bearing a his photo and
signature as competent evidence of identity.

Doc. No. ;
Page No. ;
Book No. ;
Series of 2016.