REPUBLIC OF THE PHILIPPINES )

_________________ )S.S.

AFFIDAVIT OF LOSS

I, ______________________________, Filipino, single or married, of

legal age and a resident of
__________________________________________________________________,
after having been duly sworn in accordance with law do hereby depose
and state that:

1. On ______________, the ______________________, issued to me my

______ Identification Card with ID No.__________________.

2. I usually place my ______ card in my wallet together with the other

cards issued under my name.

3. However on or about _______________, I found out that my

________ was not in my wallet and cannot be found inside my bag.

4. I have tried searching all places where I might have left my

________, but diligent search of the same proved futile and unavailing.

5. I am executing this affidavit to attest the truth of the foregoing facts

and request for an urgent replacement of the said _________ from
______________(branch).

AFFIANT FURTHER SAYETH NAUGHT.

Affiant
REPUBLIC OF THE PHILIPPINES )
)S.S.

SUBSCRIBED and SWORN to before me a notary public in the city

above-written on the _______________, affiant exhibiting to me his Drivers
License No. ____________________issued by the Land Transportation
Office and valid until ___________.

NOTARY PUBLIC FOR ____________________ CITY

Commission expires on _______________________
Roll of Attorneys No. _______________________
PTR No. _______________________
IBP No. _______________________
Office Address: _______________________

Doc. No. ______

Page No. ______
Book No. ______
Series No. 2016.