AFFIDAVIT OF LOSS

REPUBLIC OF THE PHILIPPINES)

CITY OF MANILA
) S.S.
I, Indonesian national, of legal age, residing at Asian
Mansion Condominium, Dela Rosa St., Legazpi Village, Makati City,
after having been sworn in accordance with law hereby depose
and state:
That sometime in July 14, 2014 (Monday), when I arrived
home from work, I discovered that my small pouch containing
my AEP Card and my Indonesian issued ATM Card was no longer
in the place where I used to put it and could no longer be found;
That I took pains to look for said small pouch containing my
AEP and ATM Cards;
That I am executing this affidavit to attest to the truth of the
foregoing and to request the DOLE-NCR of issuance of a
replacement AEP Card.
IN WITNESS WHEREOF, I have hereunto set my hand this
24 day of July, 2104 in the City of Manila.
th

Affiant
SUBSCRIBED AND SWORN to before me, this 24th day of
July, 2014, in the City of Manila, with affiant exhibiting her
Indonesian Passport with No. _______issued by KBRI Manila on
September 20, 2010.

Doc. No.:_________;
Page No.:_________;
Book No.:_________;
Series of 2014