Republic of the Philippines)Ss.

In the City of Davao.............)

x-----------------------------------x

AFFIDAVIT OF LOSS

I, ___________________, of legal age, Filipino, single and a resident of

_________________, Davao City, after having been duly sworn in accordance with law hereby
depose and say:

1. That on ____________ at ______ o’clock in the afternoon, while I was at

_________________, Davao City, I discovered that my wallet was missing;

2. That the same may have fell down from the pocket of my pants;

3. That my wallet contained valuable personal effects, such as the following:

a)
b)
c)
d)
e)

4. That I exerted efforts to find my missing wallet but all efforts proved unavailing;

5. That I am certain that my wallet together with the contents which are
enumerated above are totally lost and beyond recovery;

6. That I am executing this affidavit to attest to the veracity of the foregoing

declarations as true and correct and to apprise the proper authorities of the same.

IN WITNESS WHEREOF, I have hereunto affixed my signature this

____________________ in the City of Davao, Philippines.

________________
Affiant

SUBSCRIBED AND SWORN to before me this ___________________ in the City of

Davao, Philippines. Affiant exhibited to me his/her valid and competent
____________________.

Doc. No. _______;

Page No. _______;
Book No. _______;
Series of 2021.