Republic of the Philippines )

__________________________ ) S.S.

AFFIDAVIT OF LOSS
I, _________________________________, of legal age, Filipino, ____________, and a resident
of _________________________________________________________, after having been duly sworn to
in accordance with law, hereby depose and state that:

1. I am employed as ________________________________________ of
_________________________________________________, a company located at
________________________________________________________________________.

2. On _________________________ 201____ at __________ A.M./P.M., I loss the item/s

indicated hereunder:

□ ID Card/s as follows: □ ATM Card/s as follows:

_____________________________ _____________________________
_____________________________ _____________________________

□ Other important document/s as follows:

_____________________________ _____________________________
_____________________________ _____________________________

3. The loss was due to the incident or circumstance cited below:

□ Item was unintentionally □ Item was accidentally dropped

misplaced; at ___________________________;

□ Stolen/Snatched/Robbed □ Item was inadvertently burned/

at _________________________; disposed of/destroyed/damaged;

□ Other reason/s: _______________________________________________________

_______________________________________________________________________
_______________________________________________________________________.

4. The above item/s is/are now considered as completely lost and beyond recovery as I
failed to locate/retrieve the same despite diligent efforts.

5. I am executing this affidavit to attest to the truth of the foregoing statement and secure
replacement/s of the lost item/s.

AFFIANT FUTHER SAYS NONE.

____________________________________
Affiant

SUBSCRIBED AND SWORN to before me, this _________________________ 20_____, by the

affiant whom I have identified through his/her Competent Evidence of Identity which is his/her
____________________________ ID No. ______________________________ issued on
_____________________________ at _______________________________________________.

Doc. No. ______;

Page No. ______;
Book No.______;
Series of 20____.