REPUBLIC OF THE PHILIPPINES )

CITY OF CEBU ) S.S.

AFFIDAVIT OF LOSS

I, ___________________, Filipino, of legal age, single and a resident of CEBU CITY, after having duly
sworn to in accordance with law, hereby depose and say that:

1. I am a holder of a Geodetic Engineer’s Identification Card issued by Professional Regulation

Commission;
2. I lost said Identification Card on April, 23 2018 and that I exerted all efforts to locate the same but
I could not remember exactly where I placed it and it is considered lost for all legal purposes;
3. Said Identification Card was not confiscated by any officer of the law by reason of any violation of
any law, ordinance, presidential decree or rules and regulation of the said Commission; and
neither was it offered as collateral for any loan;

I am executing this affidavit to attest to the foregoing facts;

IN WITNESS WHEREOF, I have hereunto set my hand this 26th of April in CEBU city, Philippines.

______________________
Affiant

SUBSCRIBED AND SWORN to before me this _______________ in the City of __________, Philippines,
affiant having exhibited to me his/her community tax certificate with no. __________________ issued
on _________________ at ______________ .

Doc. No. ________;

Page No. ________;
Book No.________;
Series of 2018.