Republic of the Philippines)

City of Dumaguete ……. ) S.S.

X------------------

AFFIDAVIT OF LOSS

I, ERICA M. OCUREZA, Filipino, of legal age, single and a resident of Lazi, Siquijor,
Negros Oriental, Philippines, after having been sworn to in accordance with law do hereby depose
and say:

1. That I am the owner of a certain Banco De Oro (BDO) ATM Card issued by the
BDO Dumaguete City Branch and Driver’s License issued by the Land Transportation
Office (LTO) - Siquijor;

2. That sometime during the 1st week of July, 2019, I lost my wallet containing the said
ATM Card and Driver’s License while I was travelling downtown;

3. That I took pains to look for the ATM Card and Driver’s License but to no avail;

4. That earnest efforts has been exerted by me to locate the said wallet together with
ATM Card and Driver’s License, but to no avail up to the present, thus, I now consider
the same as forever lost and beyond recovery;

5. That I am executing this affidavit to attest to the truth and veracity of the foregoing
declarations and to support whatever purposes this may lawfully serve.

IN WITNESS WHEREOF, I have hereunto affixed my signature this

__________________ 2019 at Dumaguete City, Philippines.

ERICA M. OCUREZA
Affiant

SUBSCRIBED AND SWORN to before me this _________________ 2019 at Dumaguete

City, Negros Oriental, Philippines. Affiant exhibited her School ID Card No. 18-3-00157.

Doc. No._____;
Page No._____;
Book No._____;
Series of 2019.
Republic of the Philippines)
City of Dumaguete ……. ) S.S.
X------------------

AFFIDAVIT OF LOSS

I, ______________________, of legal age, Filipino citizen, single, and a resident

of Barangay Taclobo, Dumaguete City, Negros Oriental, Philippines, after having been
sworn to in accordance with law do hereby depose and say:

1. That I am a holder of TIN Card duly issued by the Bureau of Internal

Revenue (BIR), Robinsons ID duly issued by Robinsons and Voter’s ID
duly issued by COMELEC, Dumaguete City;

2. That I used to place the above-said cards inside my wallet together

with some other documents, papers and effects;

3. That lately, I lost my wallet containing the above-said cards and

documents together with my FIREFLY brand cellphone;

4. That earnest efforts has been exerted by me to locate the above-said wallet
containing the aforementioned cards, but to no avail, thus, I consider the
same forever lost and beyond recovery;

3. That I execute this affidavit to attest to the truth and veracity of the
foregoing declarations and to support my request for re-issuance of the
said cards, as well as for other purpose this may lawfully serve.

IN WITNESS WHEREOF, I have hereunto affixed my signature this

____________________, 2016, in Dumaguete City, Philippines.

______________________
Affiant

SUBSCRIBED AND SWORN to before me the ____________________, 2016, at

Dumaguete City, Negros Oriental, Philippines. Affiant exhibited to me his/her ___________ ID
Card No. ____________

Doc. No._____;
Page No._____;
Book No._____;
Series of 2016.