Republic of the Philippines )

____________,________ ) S.S.

AFFIDAVIT OF LOSS

KNOW ALL MEN BY THESE PRESENTS:

I, __________________________ of legal age, Filipino,

single/married, and a resident of
_______________________________________________ , after
having been sworn in accordance with law, hereby deposes and
states the following:

1. I am holder/owner/ or possessor of the following

identification card / document:
_____________________________

2. I have recently discovered the said item/s is/are

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.

Affiant

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.