REPUBLIC OF THE PHILIPPINES)

PROVINCE OF BULACAN ) S.S.

CITY OF MEYCAUAYAN )

AFFIDAVIT OF LOSS

I, ___________________, Filipino, of legal age, _____ and a resident of

_____________________________________________, after having duly sworn to in
accordance with law, hereby depose and say that:

1. I am the holder of Identification Card issued by

___________________;

2. On _________________________, at around ________________ the

evening, I lost/misplaced the above Card, in the vicinity of
_____________________where I used to work and despite diligent efforts exerted
to locate the same, the said card can no longer be found and thus, considered
lost for all legal purposes;

3. The said card is not confiscated by any officer of the law or by

reason of any violation of any law or ordinance, and neither was this offered as
collateral for any loan;

4. I am executing this affidavit to attest to the foregoing facts and in

connection with my request for the issuance of duplicate and/or replacement
of the said card.

IN WITNESS WHEREOF, I have hereunto set my hand this __________day

of ____________ in the _______________________________, Philippines.

_____________________________
Affiant

SUBSCRIBED AND SWORN to before me this __________ day of

July_______________, affiant satisfactorily proven to me his identity through his
______________________, that he is the same person who personally signed
before me the foregoing affidavit and acknowledged that he executed the same.

Doc. No. ____;

Page No: ____;
Book No. ___;
Series of 201_.