REPUBLIC OF THE PHILIPPINES)

CITY OF ________________ ) S.S.

x----------------------------------x

AFFIDAVIT OF LOSS

I, ____________________, of legal age, widower, Filipino, and with

residence and postal address at Sabang, Pagsanjan, after having
been duly sworn to in accordance with law, depose and
state THAT:

1. I possess a Voters ID issued by Commission on Elections

(COMELEC);

2. Sometime in 2011, I placed it in my files together with other

pertinent documents but when I looked for it, the same could not
be found;

3. Despite diligent search and efforts to locate the ID, I could not
find the same such that I believe that it is now lost beyond
recovery;

4. As such, I am executing this affidavit to attest to the foregoing

facts and to support the application for the issuance of a new one
in lieu of the one which was lost.

IN WITNESS WHEREOF, I have hereunto set my hand

this 18th day of December 2016 in
______________________________________, Philippines.

Affiant

SUBCRIBED AND SWORN TO before me this 18th day of

December 2016 in the City of___________________, Philippines,
affiant exhibiting to me his valid proof of identification.

Notary Publci