REPUBLIC OF THE PHILIPPINES  

      )
CITY AND PROVINCE OF ___________ ) S.S

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

AFFIDAVIT OF LOSS
     I, __________________________, of legal age, Filipino and a resident of (Affiant’s
complete address), Philippines, after having been duly sworn to in accordance with law,
do hereby depose and say that:

1. (State that you are the owner or holder of the document, ID, Certificate of Title
for transfer, or things that you lost, and the office, agency, institution, or person
who issued the same, see the example of a lost Driver’s License)I am the owner
of a Driver’s License duly issued by the Land Transportation Office (LTO) and
registered in my name;
2. (State the place or circumstance which you normally kept the said object which
was lost)I have usually kept the same license inside my wallet and brings with
me wherever I go;
3. (State how you lost the object)Few weeks ago, I went to ______ City to buy
some stuffs however upon arrival at my destination, I noticed that I lost my wallet
including my Driver’s License;
4. (If applicable, state your effort/s to find the lost object and the reason why it
cannot be found)I tried to look for the same traversing back my path wherein I
could possibly dropped my wallet and asked some people along the way but
despite my efforts of finding the wallet, my search for it and my hopes of finding
the same proved futile;
5. (Your declaration that the object was lost and beyond recovery)Because of this, I
declared the same to be lost and cannot be found; and
6. (The purpose on why you executed this affidavit which commonly includes to
replace the same)I am executing this Affidavit in order to attest to the truth of the
foregoing facts and for other legal purpose(s) this may serve best.

  

 IN WITNESS WHEREOF, I have hereunto set my hand this __(Date)________at

________City, Philippines.

____________________________________
Affiant
 
 
 The affiant, whose name and personal circumstances are stated above, personally
appeared before me this __________ in the City/Province of _______, Philippines,
presented the foregoing affidavit, signed the same in my presence and affirmed under
oath to the correctness of the contents or allegations of the same.
     The affiant was identified by competent evidence of identity, namely a (must be a
Government issued ID) bearing his photograph and signature.

     WITNESS MY HAND AND SEAL on the place and date above-mentioned.

Doc. No. ____;                                                   NOTARY PUBLIC 

Page No. ____; 
Book No. ____;
Series of 202_.