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Affidavit of Loss Sample PDF
Affidavit of Loss Sample PDF
AFFIDAVIT OF LOSS
postal address at Blk. 54 Lot 21, Duhat St., Zone 1 Brgy. Rizal, Pembo, Makati City,
after being sworn to in accordance with law, depose and say that:
address at the 6th Floor, Country Space 1 Bldg., Sen. Gil Puyat Avenue, Makati City;
2) As such, I was provided by our employer with several Identification Cards such as
our Company ID, PHILHEALTH ID, BPI ATM CARD and I was likewise required to procure
3) In my everyday way to and from the office, I used to drive my personal service
4) However, last December 16, 2005, after arriving from office, I was just surprised
to have known that my wallet containing all my important IDENTIFICATION CARDS, was
already missing as it might have accidentally fell-off from the back-pocket of my pants then
5) Diligent efforts have already been exerted to locate and/or retrieve my wallet
(SSS ID, PHILHEALTH ID, ATM CARDS, CREDIT CARDS, etc.) in furtherance of my
personal transactions and such other business transactions which may require the
7) This affidavit is being executed to attest to the veracity of the foregoing facts and
JOEBERTO E. EJANDRA
Affiant
NOTARY PUBLIC
DOC. NO._____;
PAGE NO._____;
BOOK NO._____;
SERIES OF 2005.
Republic of the Philippines}
City of Makati} S.S.
AFFIDAVIT OF LOSS
I, EDRALYN T. SUMALINOG , of legal age, single, with residence and postal address at
# 57 Iba St., Dapitan, Quezon City, after being sworn in accordance with law, depose and say that:
1) I am an employee of RAYOMAR MANAGEMENT, INC., with office address at the 10th Floor,
2) As such, I was provided by our employer with several Identification Cards such as
our Company ID, PHILHEALTH ID, BPI ATM CARD and I was likewise required to procure our
3) In my everyday way to and from the office, I used to commute in Public Utility Vehicles such as
jeepney, bus and/or Light Rail Transit (LRT), carrying my office handbag containing my valuables including
4) However, sometime in the later week of March 2005, after arriving from office, I was just
surprised to have known that my wallet containing all my important IDENTIFICATION CARDS, was already
missing as it might have been forcibly taken out from my bag which was then slashed on its upper right side
corner ;
5) Diligent efforts have already been exerted to retrieve my wallet along with my IDs, but all turned
out futile, as the same might had accidentally fell or could have been snatched from my pocket when I
6) I have to request for the re-issuance of these new IDENTIFICATION CARDS (SSS ID,
PHILHEALTH ID, ATM CARDS, CREDIT CARDS, etc.) in furtherance of my personal transactions and such
other business transactions which may require the presentation of those aforementioned missing IDs;
7) This affidavit is being executed to attest to the veracity of the foregoing facts and for whatever
EDRALYN T. SUMALINOG
Affiant
NOTARY PUBLIC
DOC. NO._____;
PAGE NO._____;
BOOK NO._____;
SERIES OF 2005.