Republic of the Philippines)

{{In which city will you have it notarized}})S.S.

x ------------------------------------------- x

AFFIDAVIT OF LOSS

I, {{What is your name}}, of legal age, {{what is your nationality}},

{{What is your civil status}}, and a resident of {{ where do you live}},
after having been sworn to in accordance with law, hereby depose
and say: -That-
1. I am a holder of Unified Multipurpose I.D with CRN {{What is
the CRN NO. indicated in the ID}};
2. I usually kept my Unified Multipurpose I.D in my {{where do
you usually kept it - example bag or wallet?}};
3. On {{when did you find out that it was lost}}, I was surprised
to have known that it was missing;
4. Diligent efforts have already been exerted to locate it, but all
turned out futile;
5. This affidavit is executed to certify the loss of the
abovementioned Diploma and for any legal purpose it may
serve.

IN WITNESS WHEREOF, I have hereunto affixed my signature

this {{when do you execute this document}}, in the {{ same city of the
place of notarization}}.

{{What is your full Name}}

Affiant

SUBSCRIBED AND SWORN TO before me in the City of {{In

which city will you have it notarized}} this {{when will you have it
notarized}}, affiant personally appeared with
his/her__________________________________________________
____as competent evidence of his/her identity.

Doc. No.___; NOTARY PUBLIC

Page No.___;
Book No.____;
Series of 2020.