REPUBLIC OF THE PHILIPPINES)

City of Sanfernando, Pampanga) SS.

Affidavit of Loss

I, Angelica Marie Tubo Valdez, 20 of legal age and residing/with address at Fortune Ville 1,

Baliti Pampanga, under oath, state:

1. That on January 4, 2020 around 4 in the afternoon. I was surprised to have known that my

wallet was already missing as it might have accidentally fell-off from my pants when I was

riding a jeep on my way home.

2. THAT my wallet where I put Government ID, Driver’s License, ATM Cards, Philippine

National ID and some money bills were missing.

3. I exerted diligence efforts to locate my Bag or to identify the culprit but to no avail and I

therefore considered the same as lost and cannot be found.

4. THAT I have to request for the re-issuance of these new IDENTIFICATION CARDS

(Driver’s License ATM Cards and Philippine National ID) in furtherance of my personal

transaction and such other business transaction which may require the presentation of those

aforementioned missing ID’s

5. 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 10th day of January, 2020 at

Sanfernando, Pampanga

Alrdin Caparas

Affiant
 SUBSCRIBED & SWORN to before me in the City of San Fernando, Pampanga, this

10th day of January 2020, by ANGELICA MARIE T. VALDEZ, who has satisfactorily proven

to me her identity through her COMELEC ID No. ABC 09874-846238-ALSJDOWJSDK1-8,

issued by the COMELEC that she is the same person who personally signed before me the

foregoing affidavit and acknowledge that she executed the same.

Doc. No 084 Notary Public

Page No. 45

Book No. XLI

Series of 2020
Parts of the Affidavit of Loss:
An Affidavit of Loss contains the following essential parts:

1. Title of the document

2. Your name, statement that you are of legal age, civil status, citizenship, and
residence address.
3. A narration of the circumstances of the loss, which includes (i) description of
the item or document lost; (ii) description of how it got lost; (iii) the effort
exerted to find it; and (iv) your request for a replacement of the item or
document lost.
4. The signature of the affiant. Affiant is the person executing/signing the
document.
5. The jurat. The jurat is the oath or affirmation before the notary public that you
have personally executed the document in the presence of the notary.