Republic of the Philippines)

City of Pasay...) SS.

AFFIDAVIT OF LOSS
I, _________________, Filipino, 20 years old, single, and presently a resident of
______________________________, with cellphone number 09___________, after having been
duly sworn to before competent authority, hereby depose and say:
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That I was born in Manila on Feb. __, 1995;

That my fathers name is __________, a citizen of Phillippines, and my mothers name is
___________________, a citizen of Phillippines;
That I acquired my Philippine citizenship by birth/naturalization;
That I am an owner of _____________ ;
That the circumstances about the loss of the _____ are as follows:
Last October __, 2014, at around 6-7 PM,_________________________
____________________________________________________________________
_______________________________________________________________

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That I was unable to find said _________despite diligent search, and;

That I am executing this affidavit for the information of all the authorities concerned and
for the purpose of enrolment.
IN WITNESS WHEREOF, I have hereunto affixed my signature on this __ day of
_________ 20___ in PASAY CITY, PHILIPPINES.
____________________
Affiant

SUBSCRIBED AND SWORN to before me this _______day of ________

__ 20 _____ in Pasay City, Philippines.
Doc. No. _______
Book No. _______
Page No.________
Series of ________
OR No. ________