REPUBLIC OF THE PHILIPPINES)

PASIG CITY ) S.S.

AFFIDAVIT OF LOSS

I, [NAME], of legal age, Filipino, single, residing in [home address], subscribing under
oath, depose and state:

1. That I am a holder of a [Type of ID] with number _____ (the “ID”);

2. That I used to put the ID in my purse which is kept in my residence;

3. That on the evening of [insert date], I discovered that the ID was not in my
purse and was no longer with me;

4. That diligent efforts to locate the Passport proved futile; and

5. That I am executing this affidavit to attest to the truth of the foregoing facts
and for the purposes of obtaining a new ID.

AFFIANT FURTHER SAYS NONE.

IN WITNESS HEREOF, I have set upon my hand this [date] in the City of Pasig.

[NAME]
Affiant

SUBSCRIBED AND SWORN TO before me this [date] in the City of Pasig, affiant
exhibiting to me the following:

Competent Evidence of Identity

Type of Government- ID Number and Expiry Date
Affiant issued ID

[NAME] [Type of ID (e.g., [Number and Expiry Date]

Driver’s License]

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 2020.