Republic of the Philippines)

City of Iligan . . . . . . . . . . . . . . )Sc.

AFFIDAVIT OF LOSS
I, ____________________________________________, of legal age,
Filipino Citizen, and a resident of ______________________________, after having
duly sworn to an oath as required by law, hereby depose and say:

1. That I am the ___________(relation) of ___________________________(name)

who used to be the owner of the following ID/ATM/documents/instruments, to
wit: (check appropriate box/es)

☐Automatic Teller Machine Card ☐Barangay ID

☐Company ID ☐OSCA ID
☐Passbook ID (_______________) ☐ PhilHeatlh ID
☐Postal ID ☐Philippine Regulation Commission ID
☐Social Security System ID ☐Tax Identification Number ID
☐Unified Multi-Purpose ID ☐Voter’s ID
☐Other/s: ________________________ ☐____________________________
☐_______________________________ ☐____________________________
2. That on ____________________, the above-mentioned instrument/s was/were
lost in the following manner: (check appropriate box)

☐Misplaced ☐Stolen ☐Pick-Pocketed

☐Other: _____________________________________________

3. That I exerted all efforts to locate the said instrument/s but the same could no
longer be found and is/are now beyond recovery;

4. That I am executing this affidavit to attest to the above facts and for such
other legal purposes that this affidavit may serve.

IN WITNESS WHEREOF, I have hereunto affixed my signature in Iligan City this

_______day of _____ 2021.

____________________________
Affiant

SUBSCRIBED AND SWORN to before me this ____ day of _____ 2021 at Iligan
City, Philippines. Affiant is personally known to me and he/she has satisfactorily proven
to me hi/her identity through his/her credentials.

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 2021.