REPUBLIC OF THE PHILIPPINES )

CITY OF SAN JOSE DEL MONTE )S.S.

PROVINCE OF BULACAN )
x-------------------------------------------x

AFFIDAVIT OF LOSS

I, ____________________, of legal age, married, Filipino, with residence address

at __________________________________________________, after having been duly
sworn in accordance with law hereby depose and state, to wit:

1. That, sometime on 2017, I noticed that my ______ ID Card is missing from

my bag;

2. That, I already rummaged my belongings and failed to locate my ________

ID Card;

3. That, I exerted my best effort to find and locate my ________ ID Card where I
placed the above-stated missing but my efforts proved futile and in vain;

4. That, I cannot avail the benefits under ____________. unless I can present the
said Caritas ID

5. That, I further execute this affidavit to attest the truthfulness and veracity of
the foregoing facts and for whatever legal intent and purposes it is deemed
proper;

IN WITNESS WHEREOF, I hereby affix my signature this ___ day of _____

2018 at the City of San Jose del Monte, Bulacan.

Affiant

SUBSCRIBED AND SWORN to before me this ___ day of ______ 2018 at the
City of San Jose del Monte, Bulacan. Affiant exhibiting to me her
________________________.

NOTARY PUBLIC

Doc. No. ____:

Page No. ____;
Book No. ____;
SERIES OF 2018