Republic of the Philippines )

Davao City ) s.s.

AFFIDAVIT OF LOSS

I, __________________, of legal age, Filipino, single and a resident of

Lanang, Davao City, Philippines, upon my oath, hereby depose and state, THAT:

1. I am a holder of an ______ (what type of ID) duly issued by _________ (name

of issuer of ID) with ID No.____________ (if you can remember);

2. Sometime in _______(Narrate details wow the ID was lost). I exerted diligent

efforts to locate the same, but to no avail. For all intents and purposes, the said
ID is now considered lost and beyond recovery; and

3. I am executing this Affidavit to attest to the truth of the foregoing facts, and for
whatever legal purpose this may serve.

In testimony whereof, I have hereunto affixed my signature this

________________at Davao City, Philippines.

(name)
Affiant

SUBSCRIBED AND SWORN to before me, notary public for and in the City of
Davao, this ________________. Affiant exhibited his________________, containing his
photograph and signature as competent proof of his identity.

Doc. No. ______;

Page No. ______;
Book No. ______;
Series of 2021.