REPUBLIC OF THE PHILIPPINES

CITY OF MUNTINLUPA

)
) SS.

AFFIDAVIT OF LOSS
I, _____________________________________, of legal age, Filipino, with
residence and postal address at ____________________________________________
____________________________________, after having been duly sworn to in
accordance with law, do hereby depose and say, THAT:
1. I am a holder of _______________________________________________________
issued by ___________________________________________________________;
2. However, said ___________________________________ was lost/misplaced on
________________________ in the vicinity of ______________________________;
3. Despite diligent effort in finding the same, the same proved to be futile,
and hence, said was considered lost;
4. I execute this instrument in order to attest the truth of the above facts,
and for all the legal intents and purposes this may serve.
IN WITNESS WHEREOF, I have hereunto set my hand and affix my
signature this _______ day of _________________ in the City of Muntinlupa.

_____________________________
Affiant

SUBSCRIBED AND SWORN to before me this _____ day of ______________

in the City of Muntinlupa affiant exhibited to me his/her Competent Evidence
of Identity bearing his/her picture and signature with ID No.
_________________________________ issued by _________________________________.

Doc. No.
_____ ;
Page No.
_____ ;
Book No.
_____ ;
Series of 2013.