REPUBLIC OF THE PHILIPPINES )

BACACAY, ALBAY ) S.S.

AFFIDAVIT OF LOSS
I, NAME, married, Filipino, of legal age, with address at _____________________, after being
sworn to in accordance with law, hereby depose and state that:

1. I am a holder of a valid _________, issued by _______________;

2. Sometime in Date, I discovered that my ______ was missing, and despite diligent efforts
to search and locate the same, I could not find my ________________ and believe that
they can no longer be found;

3. For all legal intents and purposes, my ______________ is now considered lost and
beyond recovery.

4. I am executing this Affidavit to attest to the truth of the foregoing and for whatever
legal purpose/s it may serve.

FURTHER AFFIANT SAYETH NAUGHT.

IN WITNESS WHEREOF, I have hereunto set my hand this ____ day of ___________ 2019 at
Bacacay, Albay.

NAME
Affiant

SUBSCRIBED AND SWORN to before me this ____ day of _____ 2019, affiant exhibited to me her
______________________.

Doc. No. ________ ;

Page No. ________ ;
Book No. ________ ;
Series of 2019.