Republic of the Philippines)

PARANAQUE CITY ) SS.

AFFIDAVIT OF LOSS

I, _______________________________, Filipino, of legal age, married, and with residence address at

_______________________________, Parañaque City, Philippines, after being duly sworn to in
accordance with law, hereby depose and state:

That on _______________________________, Sunday, at around 5:00 to 9:00 PM, I parked my

vehicle at _______________________________;

That I am certain that my sling bag, that contains my wallet, money, ATM Cards and IDs:

1. LTO Driver’s License

2. SSS Member’s ID
3. Pag-Ibig (HDMF) Member’s ID
4. Bank of the Philippines Island (BPI) ATM Card
5. Other Club and Association IDs,

were left inside the vehicle while we are dining at the restaurant;

That upon arriving at our residence in Parañaque City, I noticed that my sling bag was missing;

That despite diligent search and efforts to locate my lost/missing sling bag that contain important
cards and IDs, I could not find them such that I now believe that they are now lost beyond
recovery.

That my Driver’s License has not been confiscated by the LTO, Police, or any traffic enforcers, for
any traffic violation.

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing facts and to
support my application for the issuance of a new Driver’s License, Membership and ATM Cards,
in lieu of the ones that were lost.

IN WITNESS WHEREOF, I have hereunto set my hand this _____________ at _____________,

Philippines.

_______________________________
Affiant

SUBSCRIBED AND SWORN to before me this _______________ at _______________, Affiant

exhibiting to me his __________________________________ with No. ________________ issued at
_________________ on ___________________________.

Doc No. ________;

Page No. _______;
Book No. _______; NOTARY PUBLIC
Series of 2017