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. Signed on the date and at the
place indicated below. 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
________________, ______________________, Philip