REPUBLIC OF THE PHILIPPINES )

QUEZON CITY, METRO MANILA ) S.S.

AFFIDAVIT OF LOSS

I, __________________, of legal age and a resident of

______________________________, do hereby depose and state that:

1. I am the holder of the following item;

2. The said item was (please check/write the reason):

Irretrievably misplaced Beyond repair

Stolen / robbed Lost
Damaged Other reason:

3. I exerted utmost effort to locate / recover / repair the said item but all proved futile.
Hence, I now consider it lost and beyond recovery;

4. I have never sold, pawned, swapped, exchanged or given the aforesaid item in
exchange for any consideration, neither the same has confiscated by the authorities;

5. This affidavit is executed to make a formal report of the fact of loss of the aforesaid
item and to request for the replacement of the same.

IN WITNESS WHEREOF, I have hereunto affixed my signature at the place and on the
date mentioned in the Jurat.

Affiant (Name and Signature)

SUBSCRIBED AND SWORN TO before this _____ day of_____________ 2019 in

Quezon City. Affiant is personally known to the Notary Public and exhibited her proof of
identity: ____________________.

Doc. No.
Page No.
Book No.
Series of 2019