____________,_____________
)
) S.S.
AFFIDAVIT OF LOSS
Affiant
(Signature over Printed Name)
Competent Evidence of Identity
ID:
issued on:
at:
SUBSCRIBED and SWORN TO before me on the date and at the place indicated below. The
affiant exhibited to me his competent evidence of identity as indicated above.
Signed this ______________at ________________, ______________________, Philippines.
WITNESS MY HAND AND SEAL.
Notary Public
Doc. No.
Page No.
Book No. I
Series of