Affidavit of Loss

REPUBLIC OF THE PHILIPPINES)

Province/City__________________ ) SS.

AFFIDAVIT OF LOSS
I, ________(name)_______, of legal age and residing/with address at ____________________,
under oath, state:

1. THAT on ______(date)_____ at _________(place) _________ while _________ (describe

how loss occurred) ___________;

Example:

“1. THAT on 28 February 2005 while riding on a jeepney on my way home, my wallet was pick-
pocketed without my knowledge;”

2. THAT ___________________(describe the particulars of what was lost)_____;

Example:

“2. THAT my wallet contained my school ID, my Driver’s License and some money bills;”

3. THAT I exerted diligent efforts to locate _____(the thing lost)____ or but to no avail and I
therefore considered the same as lost and can no longer be found;

Example:

“3. THAT I exerted diligence efforts to locate my wallet or identify the culprit but to no avail and
I therefore considered the same as lost and cannot be found;”

4. 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 _______________ at

__________________.

__________(name)________
Affiant