REPUBLIC OF THE PHILIPPINES)

CITY OF ) S.S.

AFFIDAVIT OF LOSS

I, (your name), of legal age, Filipino, with residence address at

_______________________________________________________, employee of (Company’s name), after
being sworn to in accordance with law, depose and states;

1. That (company’s Name) with office address at (office address) issued (what was loss
and what is it for).

2. That the above mentioned (what was loss) was misplace/loss and despite diligent
efforts to locate said (what was loss), the same could not be found.

3. That I have executed this affidavit freely and voluntarily for all legal intents and
purposed and to support the issuance of replacement of (what was loss) provided by
(Company’s Name).

I, witness whereof, I have signed this affidavit this _______ day of ___________________ at
______________, Philippines.

(printed name over signature)

WITNESSETH:

________________________________________ ___________________________________________

SUBSCRIBED AND SWORN TO before me this _________________________ , affiant, who is

personally known to me avowed under penalty of law to the whole truth of the contents
thereof, and exhibited her (2 Gov’t issued ID)
to prove her identity

Doc. No.: ______

Page No.: ______
Book No.: ______ Notary Public
Series of 2018.