REPUBLIC OF THE PHILIPPINES )

Quezon City ) SS.

AFFIDAVIT OF LOSS

I, MARIA CONCEPCION D. NICO, Filipino, of legal age, and a resident of 1842 Ibarra
St. Sampaloc Manila, after having been duly sworn in accordance with law, hereby
depose and say:

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

employee number 000131;

2. That I used to put said identification card in my pouch.

3. That sometime on December 29, 2016 when I arrived home from

work, I discovered that my company ID card was no longer in my
pouch where I used to place it;

4. Despite diligent search and efforts to locate said document, I could

not find it.

5. That said company ID card was not confiscated by the authorities

of Company by reason of any violation of company rules and
regulations;

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

foregoing facts and to request for replacement of said company ID
card.

_____________________________
Affiant

SUBSCRIBED AND SWORN to before me, this ____ day of January 2017 in _________
City, with affiant exhibiting her Unified Multi-Purpose ID No. CRN.0111.3086953-4
issued by SSS.

Doc. No. : ________;

Page No. : ________;
Book No. : ________;
Series of 2017.