Republic of the Philippines)

City of Butuan )S.S.

AFFIDAVIT OF LOSS

I, _____________________, of legal age, Filipino and a

resident of _____________________________________________
after having been duly sworn according to law depose and state:

1. That I am a holder of a _______________________ issued by

the ______________________, ___________________;

2. That I lost the said ____________________ sometime on

______________________and that I exerted all efforts to
locate the same but could not remember exactly where I placed
it and considered it lost for all legal purposes;

3. That the said ___________________ was not confiscated by

any officer of the law by reason of any violation of any law,
ordinance or presidential decree, rules or regulation of the said
Office;

4. That I am executing this Affidavit to inform the

_______________ that the said __________________ was
lost and never recovered; and

5. That I attest to the truth of the foregoing facts.

FURTHER AFFIANT SAYETH NONE.

IN WITNESS WHEREOF, I have hereunto set my hand this

__________________ in Butuan City, Philippines.

______________________
Affiant

SUBSCRIBED and SWORN TO before me this ______________

in Butuan City, affiant exhibiting to me his _______________. with
Picture and Registration No. 0492004.

Doc. No._______
Page No._______
Book No._______
Series of 2017