REPUBLIC OF THE 

PHILIPPINES )
Province/City__________________  ) SS.

AFFIDAVIT OF LOSS
I, ________(name)_______, of legal age and residing/with address at
_________________________________________,  under oath, state:
1.                 THAT on ______(date)_____ at _________(place)_________
while _________(describe how loss occurred)___________;
Example:
“1.     THAT on 28 February 2005 while riding on a jeepney on my way
home, my wallet was pick-pocketed without my knowledge; “
2.                 THAT ___________________(describe the particulars of
what was lost)_____;
Example:
“2.     THAT my wallet contained my school ID, my Driver’s License and
some money bills;
3.       THAT I exerted diligent efforts to locate _____(the thing lost)____ or
but to no avail and I therefore considered the same as lost and can no longer
be found;
Example:
“3.     THAT I exerted diligence efforts to locate my wallet or identify
the culprit but to no avail and I therefore considered the same as lost
and cannot be found;
4.       THAT I am executing this Affidavit to attest to the truth of the
foregoing facts and to use the same for whatever legal purpose it may serve.
IN WITNESS WHEREOF, I hereunto affix my signature this
_______________  at __________________.
__________(name)________
Affiant
SUBSCRIBED AND SWORN to before me this _______________ at
__________________, Affiant exhibiting to me his Community Tax
Certificate bearing No. ________________ issued at _________________
on ___________________________.
Doc No. ________;
Page No. _______ ;
Book No. _______;
Series of 2005.