REPUBLIC OF THE PHILIPPINES )

Province of____________________) S.S.

City/Municipality of______________)
x---------------------------------------x

AFFIDAVIT OF LOSS

I, ______________(name of affiant)__________________, Filipino,

of legal age, [single]/[married to ___________(name of
spouse)_______], and a resident of ___________(address of
affiant)____________, after having been duly sworn in accordance
with law, hereby depose and state:

1. That I am Registered Nurse;

2. That on ____________________________ at around

______________, while I was at the _________________ at
______________________, I lost my wallet which I usually
place in my left front pocket;

3. That inside the said wallet are my Professional ID Card with

Registration No. _____ issued by the Professional Regulation
Commission on ________(date issued)____________ and my
ATM Card issued by _______________________ Bank,
_____________ Branch;

4. That I now believe that they are now lost beyond recovery
because despite diligent search and efforts to locate the said
wallet with my Professional ID Card and my ATM Card, I could
not find them;

5. As such, I am executing this Affidavit of Loss to attest to the

truth of the foregoing and to support my application for the
issuance of a new Professional ID Card and block my ATM
Account from possible cash withdrawal by others.

IN WITNESS WHEREOF, I have hereunto set my hand this

_____________ at _____________, Philippines.

_________________________________
Affiant

SUBSCRIBED AND SWORN TO BEFORE ME, a notary public in and for

_________(City/Province)____________ this ____th day of ____________
20___. Affiant personally came and appeared with _____________(Competent
Evidence of Identity)______ issued by the _________(Government
Agency)______ on ___(date)__ at ________(place)_________, bearing his
photograph and signature, known to me as the same person who personally
signed the foregoing instrument before me and avowed under penalty of law to
the whole truth of the contents of said instrument.

Atty _______________________________________
Notary Public
Doc. No. ____ Commission Serial No. __________________
Page No. ____ Notary Public for _______(Province/City)_____
Book No. ____ Until December 31, 20__
Series of 20__ Office: ______________(address)__________
Roll No. __________
IBP Lifetime Roll No. ________; __/__/__ ; (Province)
PTR No. _________ ; __/__/__ ; _(Province)_
MCLE Compliance Cert. No. __________; __/__/__
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