Republic of the Philippines )

_____________________
)S.S.
_____________________
)
x - - - - - - - - - - - - - - - - - - - - -x
AFFIDAVIT OF LOSS
I, ___________________________, of legal age, Filipino, and a resident of
___________________________________, after having been duly sworn to in
accordance with law, hereby depose and say:
1. That I am the same person executing this affidavit;
2. That I am an owner of an _______________________ issued by the
___________________________;
3. That on _________________, I went to the ______________________
bringing with me my pouch containing the above-mentioned
__________________.
Moments
later,
I
noticed
that
my
____________________ was no longer in my pouch, hence I exerted my
best effort to locate the said _____________________, but all my efforts
were in vain;
4. That the said ___________________________is now considered lost and
beyond recovery;
5. That I am executing this affidavit to attest to the truth of the foregoing for
whatever lawful purpose that it may serve and to notify and request the
_______________________________ regarding such loss and for the
issuance of a new ___________________ in place of the lost one;

IN WITNESS WHEREOF, I have hereunto set my hand this ___ day of

______________, 2014 at _____________________________.

Affiant

SUBSCRIBED AND SWORN to before me this ___ day of ______________,

2014 at ____________________________.

Doc No. _____

Page No. _____
Book No . _____
Series of 2014.