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Republic of the Philippines )

__________,_____________ ) S.S.

AFFIDAVIT OF LOSS

KNOWN ALL MEN BY THESE PRESENTS:


I, Princess Diane F. Dela Peña, of legal age, Filipino, single, and a resident of #14 H. Monroy
St., Navotas West, Navotas City after having been sworn in accordance with law, hereby deposes and
states the following:

1. I am a holder/ owner/ possessor of the following identification card/ document: COMPANY ID

2. I have recently discovered the said item is irretrievably lost and can no longer be found despite
diligent efforts to locate the same;

3. I execute this affidavit to attest to the truth of the foregoing.

Signed on the date and at the place indicated below.

Affiant
Princess Diane F. Dela Peña
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 her confident evidence of identity as given above.

Signed this __________________ at ______________________,________________,Philippines.

WITNESS MY HAND AND SEAL.

Notary Public

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Book no. 1
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