AFFIDAVIT OF LOSS

I, __________________________, of legal age, Filipino, single/married, and resident of

___________________________________________, after being duly sworn according to law,

hereby depose and state that:

1. That I am a holder of a company identification card bearing serial number

______________________ issued by _______________;

2. Sometime in April 11, 2014 at 2:45pm, I lost the above company ID under the following
circumstances:

When I arrived at the office from ________________, I discovered that my company ID was no
longer in my sling.

3. Despite diligent efforts exerted, I could no longer locate, find or recover the said company ID
and to the best of my knowledge, the same is truly lost.

4. The said company ID has not been confiscated by any officer of the law or the issuing office
or agency due to the violation of any law, statute, order, rule or regulation.

5. In the event that the lost company ID should hereafter be found or located, I undertake to
forward or surrender the same to _______________. for appropriate disposal.

6. I am executing this Affidavit to attest to the truth of the foregoing statements and to request
the issuance of a new company ID in lieu of the one which was lost.
AFFIANT FURTHER SAYETH NAUGHT.

IN WITNESS WHEREOF, I have hereunto set my hand on this 12th day of April 2014 in Cebu
City, Philippines.

__________________________________________

Affiant

SUBSCRIBED AND SWORN to before me this 12th day of April 2014 in Cebu City,
Philippines.

Doc. No. ______;

Page No. ______;

Book No. ______;

Series of ______