REPUBLIC OF THE PHILIPPINES )

AMADEO, CAVITE )S.S

AFFIDAVIT OF LOSS

I, ________________ Filipino, of legal age, single, and with postal address at

__________________, after being duly sworn in accordance with law, depose and state:

1. That I am a holder of an ATM with account number ______________ issued by

Land Bank of the Philippines;

2. That I am also a duly licensed driver in accordance with pertinent Land

Transportation laws, rules and regulations, and was issued a corresponding Non-
Professional Driver’s License with number _________________ which is valid until
____________ issued by the Land Transportation Office;

3. That I am also a holder of a TIN Card/I.D with No. __________ issued by the Bureau
of Internal Revenue (BIR);

4. That I used to put said IDs and ATM card inside my wallet. Sometime on
_________________, I went to ______________ and only upon returning home that I
noticed my wallet was already missing.

5. That diligent efforts have already been exerted to retrieve the above-mentioned cards
but all turned out futile;

6. As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
and to request for a replacement of my ATM-Land Bank card, Driver’s License and
TIN ID.

IN WITNESS WHEREOF, I have hereunto set my hand this _____ day of ____ 2020 at
___________.

_________________
Affiant

SUBSCRIBED AND SWORN to before me, this ____ day of _______ 2020 by the
Affiant whom I have identified through competent evidence of identity and who exhibited his
_____________ issued at _______ on ___________.

Doc. No. _____;

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