Republic of the Philippines)

City of _________________________)

AFFIDAVIT OF LOSS

I, ____________________, of legal age, Filipino, single/married and resident of______________________,

having been duly sworn to, hereby depose and say:

1. That I am an employee of ___________________________;

2. That I was issued by _______________________ of a ___________________________;

3. That on ______________________ the said __________________ was ______________________;

4. That the said ______________________ can no longer be located, retrieve or recovered

despite diligent efforts and is considered loss/missing.

5. That this affidavit is being made for purposes of _______________________________ and for
whatever legal purpose this may serve.

IN WITNESS WHEREOF, I have signed this affidavit this ___________________ at

__________________________.

___________________________________
Affiant

SUBSCRIBED AND SWORN TO before me, by the affiant who presented her
________________________________________________ who is also PERSONALLY KNOWN TO ME, as the same
person who made this subscription.

Witness my hand and seal this on ____________________________ at __________________________________.

Doc. No.: ____;

Page No.: ____;
Book No.: ____;
Series of 2020.

AFFIDAVIT OF SERVICE