REPUBLIC OF THE PHILIPPINES )

Province of____________________) S.S.

City/Municipality of______________)
x---------------------------------------x
AFFIDAVIT OF LOSS
I, ______________(name of affiant)__________________, Filipino, of legal age, [single]/[married
to ___________(name of spouse)_______], and a resident of ___________(address of
affiant)____________, after having been duly sworn in accordance with law, hereby depose and
state:
1. That I am Registered Nurse;
2. That on ____________________________ at around ______________, while I was at
the _________________ at ______________________, I lost my wallet which I usually
place in my left front pocket;
3. That inside the said wallet are my Professional ID Card with Registration No. _____
issued
by
the
Professional
Regulation
Commission
on
________(date
issued)____________ and my ATM Card issued by _______________________ Bank,
_____________ Branch;
4. That I now believe that they are now lost beyond recovery because despite diligent
search and efforts to locate the said wallet with my Professional ID Card and my ATM
Card, I could not find them;
5. As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing and
to support my application for the issuance of a new Professional ID Card and block my
ATM Account from possible cash withdrawal by others.
IN WITNESS WHEREOF, I have hereunto set my hand this _____________ at _____________,
Philippines.
_________________________________
Affiant

SUBSCRIBED AND SWORN TO BEFORE ME, a notary public in and for

_________(City/Province)____________ this ____th day of ____________ 20___.
Affiant personally came and appeared with _____________(Competent Evidence of
Identity)______ issued by the _________(Government Agency)______ on ___(date)__
at ________(place)_________, bearing his photograph and signature, known to me as the
same person who personally signed the foregoing instrument before me and avowed
under penalty of law to the whole truth of the contents of said instrument.

Doc. No. ____

Atty ___________________________________________
Notary Public
Commission Serial No. ____________________________

Page No. ____

Book No. ____
Series of 20__

Notary Public for _______(Province/City)______________

Until December 31, 20__
Office: ______________(address)____________________
Roll No. __________
IBP Lifetime Roll No. _________; __/__/__ ; _(Province)_
PTR No. _________ ; __/__/__ ; _(Province)_
MCLE Compliance Cert. No. __________; __/__/__