REPUBLIC OF THE PHILIPPINES)

CITY OF _______ . . . . . . . . . . . . . . . . )S.S

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 used to a holder _________________________________;

2. That on ____________, said document was lost in the following manner:

____________________________________________________

3. That I lost no time in diligently trying to locate the said wallet to retrieve the
_______________ but all efforts exerted proved futile and to no avail, and
that the same is considered lost and beyond recovery;

4. That the said loss of _______________________ was never lent to another

person or entity nor confiscated by any other law enforcement agency;

5. That I bind myself to surrender the said _____________________ to the

district office that issued the same in the event that said Certificate of
Registration is recover;

6. That the purposes of this affidavit of loss is for securing a replacement for the
loss of my _____________________;

7. That I am executing this affidavit for the aforesaid purpose as well as for
attesting to the truth of the statements herein declared, subject to the rules on
perjury.

IN WITNESS WHEREOF, I have hereunto set my hand this ________ at ________

Philippines

__________________
Affiant

SUBSCRIBED AND SWORN to before me this ____ 2021 at ______, Philippines.

Affiant is personally known to me and her has satisfactorily proven to me her identity through
her credentials

Doc. No. ____;

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