REPUBLIC OF THE PHILIPPINES)

PROVINCE OF CEBU ) S.s.

AFFIDAVIT OF LOSS 1

I, _________________________________, of legal age, Filipino, and a resident of

____________________________________ after having been duly sworn to in accordance with law, do
hereby say, T H A T:

1. I am a bonafide holder/owner of the following:

a)

b)

c)

d)

e)

2. Last December 16 2021, a super typhoon called ODETTE with international name RIA visited the
Philippines particularly Cebu towns and cities. Odette caused severe damage to properties due to
flooding and strong winds. I am one of the thousands who are victims of the Super Typhoon
Odette. As a result of the onslaught, many of my documents and personal items perished with the
wind and the flood. Included in the lost items are the above-mentioned.

3. Due to the Super Typhoon, the items can longer be found, hence, considered lost forever;

4. I attest that the lost item was not used for illegal purposes nor to evade the obligations and the
authorities.

5. Finally, I am executing this affidavit based on personal knowledge and under pains of perjury for
the purpose of informing the authorities concerned, the fact of loss of the above-mentioned item/s
so that I’ll be issued a new one and be able to present this affidavit in lieu of that lost item/s.

IN WITNESS WHEREOF, I hereby affix my signature, this March 6, 2022 at Cordova, Cebu
Philippines.
__________________________________
Affiant

Attested by Two Witnesses: ________________________ ________________________

SUBSCRIBED AND SWORN TO before me, at the place and date above-mentioned.

Doc No.:
Page No.:
Book No.:
Series of 2022

1
This Affidavit of Loss is provided free of charge. A love project for the victims of Super Typhoon Odette by Integrated Bar of the Philippines- Cebu
Chapter.