Republic of the Philippines )

Quezon City, Metro Manila ) SS.

AFFIDAVIT OF LOSS

I, _______________________, of legal age and resident of ____________, after having been

duly sworn in accordance with law, hereby depose and state:
1.) That I was aboard a jeepney on January 19, 2016 going to our office, and I remember
placing inside my pocket the ___________________;
2.) That the said ________________________;
3.) That upon checking, I noticed that the said ______________ is not inside any of my
pockets anymore;
4.) That considering there is no other place I could have place such ______________, I have
considered it lost;
5.) That I am requesting a replacement of said _______________ containing the aforesaid
details ________________;
6.) That I am executing this affidavit of loss in order to attest to the truth of the foregoing
facts, to comply with the requirements for ______________________, and for whatever
legal purpose it may be worth.

IN WITNESS WHEREOF, I have hereunto set my hand this ______________ at Quezon

City, Metro Manila, Philippines.

_____________________
Affiant

SUBSCRIBED AND SWORN before me this ___________ at Quezon City, Metro

Manila, Philippines.

Doc. No.
Page No.
Book No.
Series of 2016