(Time) (Day) (Month) (Year) Brief Description of Incident)

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Nature of Incident:

That on or
about: (Time) (Day) (Month) (Year)

(Give brief description of incident)


_________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
_____________________________________________________________________________________.

That said COMPANY ID/TEMPORARY EMPLOYEE PASS was lost and despite
diligent efforts exerted to locate the same, it could no longer be found.

This Affidavit of Loss is executed in order to establish the foregoing fact of


loss and to request the aforestated Company to issue a new Identification Card in
lieu of the lost one.

In WITNESS WHEREOF, I have hereunto affixed my signature this _____ day


of ___________________ in the City of __________________, Philippines.

Affiant

SUBSCRIBED AND SWORN to before me this _____ day of ______________ at


____________________, Philippines, after affiant exhibited to me Community Tax
Certificate No. _______________ issued on _______________ at ____________________,
Philippines.

NOTARY PUBLIC

Doc. No. _________


Page No. _________
Book No. _________
Series of _________

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