REPUBLIC OF THE PHILIPPINES)

QUEZON CITY) S.S.

x----------------------------x
AFFIDAVIT OF LOSS

I, ____________________________, of legal age, Filipino, single and a

resident of _______________________________, after having been duly sworn to in
accordance with law, depose and state THAT:
1. I am an employee at ____________ and was issued a corresponding company
identification card (ID) number _____________ which is valid until _____________;
2. Sometime on ____________, said identification card was misplaced and got
lost;
3. Efforts were exerted to locate said ID, but in spite of diligent search, it
could not be found and the same is now beyond recovery;
4. As such, I am executing this Affidavit of Loss to attest to the truth of the
foregoing and to support my application for a new company identification
card, in lieu of the one that was lost;
IN WITNESS WHEREOF, I have hereunto set
this ___________________ in Quezon City, Metro Manila, Philippines.

my

hand

____________________
French Clifford Dacion
Affiant

SUBCRIBED AND SWORN TO before me this ___________________ in

_________________, Philippines, affiant exhibiting to me his/her competent
evidence of identity by way of __________________ issued at ______________
on __________________.
NOTARY PUBLIC
Doc. No. _____;
Page No. _____;
Book No. _____;
Series of 2016.