Republic of the Philippines )

____________,_____________ ) S.S.

AFFIDAVIT OF LOSS
KNOW ALL MEN BY THESE PRESENTS:
I, Rohayda Palawan of legal age, Filipino, 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.
The affiant exhibited to me his competent evidence of identity as indicated above
Signed this ______________at ________________, ______________________,
Philippines.

WITNESS MY HAND AND SEAL.

Notary Public Doc.

No.
Page No.
Book No. I
Series of