Republic of the Philippines )

Province of Pangasinan )
City of Dagupan ) S.S.

AFFIDAVIT OF LOSS
(Philippine Postal Identification Card)

I, (AFFIANT’S NAME), of legal age, Filipino, married to (NAME OF AFFIANT’S

SPOUSE, if any), and resident of (AFFIANT’S ADDRESS), after having been sworn in
accordance with law hereby deposes and states that:

1. I am the true and lawful owner of a Postal Identification (Postal I.D.) Card No. ( )
issued by the Philippine Postal Office of (PLACE OF OFFICE) on (DATE OF
ISSUE);

2. sometime on (DATE), I was looking for the said Postal I.D. Card, but to my surprise,
the same could not be found (ADD, CHANGE OR MODIFY BY INSERTING THE
DETAILS NEEDED ACCORDING TO THE CIRCUMSTANCES);

3. despite earnest and painful efforts on my part to search, locate and retrieve the
aforesaid Postal I.D. Card, the same proved me futile and in vain;

4. said Postal I.D. Card was not confiscated by any officer of the law or the officers of
the Philippine Postal Office by reason of any violation of any law, ordinance,
presidential decree or rules and regulations of the said office; neither was it offered as
collateral for any loan nor transferred to any person or entity nor used for any
unlawful purpose; and

5. I am executing this affidavit to attest to the truth of the foregoing, to request from the
Philippine Postal Office of (PLACE OF OFFICE) a replacement copy of the said
Postal I.D. Card, and for all legal intents and purposes this may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this ___th day of

_______________, 20___ in the City of Dagupan, Province of Pangasinan, Philippines.

_________________________________
(AFFIANT’S NAME)
Affiant