REPUBLIC OF THE PHILIPPINES )

PROVINCE OF LAGUNA )
CITY/MUNICIPALITY OF SAN PEDRO ) S.S.

AFFIDAVIT OF LOSS

I, ____________, of legal age, Filipino citizen, married, with residence and

postal address at ____________________, after having been sworn to in
accordance with law, do hereby depose and state the following:

1. I am an employee of ________________ (Company) with office address at

_____________________________;

2. As an employee of the Company, I have been granted access in or about

the company premises through an Identification Card (I.D.) bearing my
name and the company name / logo;

3. On 11 March 2015, when I was preparing to go to work, I found out that

the said I.D. was already missing from its lanyard. I believe that it must
have fell from the lanyard during my commute for home the previous day
since the I.D. Card slot punch is already damaged;

4. I have exerted all of my efforts to locate the same but to no avail;

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

and for such other legal purposes this affidavit may serve.

6. Affiant further sayeth naught.

IN WITNESS WHEREOF, I have hereunto affixed my signature this

th
____ day of _______________, 2016 in San Pedro, Laguna, Philippines.

________________
Affiant

SUBSCRIBED AND SWORN to before me, this ____th day of

_______________, 2016 in San Pedro, Laguna, affiant exhibiting to me her
Drivers License I.D. with No. _____________.

Notary Public

Doc. No. ___;

Page No. ___;
Book No. ___;
Series of 2016.