Republic of the Philippines]

Province of ______ ]
Municipality of ______ ]

AFFIDAVIT OF LOSS

KNOW ALL MEN BY THESE PRESENTS: I, __________________________ of legal age, Filipino,

single/married, and a resident of ________________________________________________ , after
having been sworn in accordance with law, hereby deposes and states the following:

1. I am holder/owner/ or possessor of the following identification card / document:

_____________________________

2. I have recently discovered the said item/s is/are irretrievably lost and can no longer be found despite
diligent efforts to locate the same;

3. I execute this affidavit to attest to the truth of the foregoing. Signed on the date and at the place
indicated below.

Affiant

(Signature over Printed Name)

Competent Evidence of Identity ID: issued on: at:

SUBSCRIBED and SWORN TO before me on the date and at the place indicated below.

affiant exhibited to me his competent evidence of identity as indicated above. Signed this
______________at ________________, ______________________, Philippines.

WITNESS MY HAND AND SEAL