REPUBLIC OF THE PHILIPPINES)

CITY OF CEBU
) S.S.
x--------------------------------/.

AFFIDAVIT OF LOSS

I, VAN BORCES PATILUNA, of legal age, Filipino, married and a resident of Tulay
Urban Homes, Cubacub, Mandaue City, after having been duly sworn to in accordance with law,
depose and state THAT :
1. Last February 13, 2016, I left my Company I.D bearing no. 066D229 at the
photocopier of USC-TC while I had it photocopied as requirements for the application of loan;
2. It was only when I arrived home that day when I noticed that my Company I.D was not
in my pocket;
3. I inquired to the in-charge of the photocopier if he noticed my Company I.D but he
responded in the negative.
4. Efforts were exerted to locate the same, but in spite of diligent search, it could not be
found creating a belief that I probably inadvertently lost it somewhere which is now beyond
recovery;
5. As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing and
for the purpose of issuance of a new Company I.D.
IN WITNESS WHEREOF, I have hereunto set my hand this 15th day of March 2016, in
Cebu City, Philippines.
VAN BORCES PATILUNA
Affiant

SUBCRIBED AND SWORN TO before me this 15th day of March in Cebu

City, Philippines, affiant exhibiting to me his competent evidence of identity by way of a
Drivers License No. G01-99-249475 issued at LTO Region VII issued on December 19, 2014.
Doc. No. _____;
Page No. _____;
Book No. _____;
Series of ______.