Republic of the Philippines )
____________,_____________ ) S.S.
AFFIDAVIT OF LOSS
I, __________________________ of legal age, Filipino, single/married, and a resident of ________________________________________________ , after having been sworn in accordance with law, hereby deposes and states the following:
1. I am holder/owner/ or possessor of the following identification card / document: _____________________________
2. I have recently discovered the said item/s is/are irretrievably lost and can no longer be found despite diligent efforts to locate the same;
3. I execute this affidavit to attest to the truth of the foregoing.
Signed on the date and at the place indicated below.
Affiant
(Signature over Printed Name)
Competent Evidence of Identity
ID:
issued on:
at:
Signed this ______________at ________________, ______________________, Philippines.
WITNESS MY HAND AND SEAL.
Notary Public
Doc. No.Page No.
Book No. I
Series of
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