REPUBLIC OF THE PHILIPPINES)

CITY OF CALOOCAN )S.S.

AFFIDAVIT OF LOSS
I, ___________________, of legal age, Filipino, and with residence and
postal address at ________________________________, after having duly sworn
to in accordance with law, hereby depose and state:
1. That I was in possession a __________________ issued by
the_______________;
2. That my said Company ID was lost and or missing;

3. That sometime on June 28, 2017 at around 2:00 A.M. , while I was

walking along the streets in Blumentritt, Sta. Cruz, manila, I notice that

my wallet containing a certain amount of cash, several documents and

ID’s including said Company ID was no longer inside the backpocket of

my pants

4. That I probably dropped my said wallet inside an unknown passenger

jeep bound to Monumento;

5. That I diligently exerted efforts to locate my wallet containing a certain

amount of cash, several documents and ID’s including said Company ID

but all prove futile as the wallet is now beyond recovery;

6. That I am executing this affidavit to attest to the truth of the foregoing

facts and for whatever purpose/s it may legally served.

AFFIANT SAYETH NAUGHT.

.
_____________________
Affiant
SUBSCRIBED AND SWORN to before me this __ day of ____ at
_____________. Affiant exhibited to me __________________.