REPUBLIC OF THE PHILIPPINES }

City of ______________ } SS

AFFIDAVIT OF LOSS

I, _______________________________, of legal age, Filipino, single, with

postal address at _________________________________________________, after
having been sworn to in accordance with law, do hereby depose and say that:

1. I have been issued the following Identification Cards:

(a)
(b)
(c)

2. I lost my card wallet containing the aforesaid Identification Cards

while I was doing some shopping at Divisoria on ___________________________.

3. Despite diligent effort, I failed to find my card wallet including my

________________________________________________________________________
_______________________________________________________________________.

4. I am executing this affidavit to attest to the truth of the aforementioned

facts, in support of my application for the issuance of a duplicate/new set of the
said Identification Cards, and for whatever legal purpose it may serve.

AFFIANT FURTHER SAYETH NAUGHT.

NAME
Affiant

SUBSCRIBED AND SWORN to before me this __ day of September 2020,

in ______________ City, affiant exhibiting to me his
___________________________ issued on _____________ at ___________________.

Doc. No. ___

Page No. ___
Book No. ___
Series of 2020.