Affidavit of Loss

Below is an example of an Affidavit of Loss for your personal use. No

redistribution of this document is allowed without our permission. You may edit
the lost items as necessary.

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.