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REPUBLIC OF THE PHILIPPINES )

____________ ) S.S.

AFFIDAVIT OF LOSS

I, ______________, of legal age, Filipino and a resident of


________________________, having duly sworn in accordance with law, hereby depose
and state:

1. That I was issued the following Identification Cards (IDs);


a. ___________,
b. ___________, and
c. ___________;

2. That I used to keep the said ____________, __________, and _________IDs in


my wallet which I usually carry with me;

3. That on __________, while I was inside the _______________, in ____________,


I had noticed that my wallet together with the said ___________, __________
and _____________ IDs was no longer with me and was lost;

4. That I had tried to look for the ___________, __________ and _____________
IDs but the same could not be found;

5. That despite diligent search and efforts to locate said ___________,


__________ and _____________IDs, I could not find the same such that I now
believe that those are now lost beyond recovery; and

6. As such, I am executing this Affidavit of Loss to attest to the truth of the


foregoing and for other legal purposes it may serve.

IN WITNESS WHEREOF, I have set my hand this ____ day of _________, in


_____________, _____________, Philippines.

________________________
Affiant

SUBSCRIBED AND SWORN to before me this _____ day of _________ in


_______________, ___________, affiant exhibited to me his/her Valid ID with No.
_____________.

NOTARY PUBLIC
Doc No. _______
Page No. ______
Book No. ______
Series of _______

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