REPUBLIC OF THE PHILIPPINES)

C I T Y O F D A V A O )s.s.
x- - - - - - - - - - - - - - -/

AFFIDAVIT OF LOSS

I, _______________ , of legal age, Filipino, married, and a resident of

_____________________, Philippines, do hereby depose and state under oath that:

1. That I am presently employed at _____________, as ______________;

2. That I am the owner/holder of an Employee Identification Card bearing ID

No. _________ issued by the _________;

3. That on _______________, I belatedly found out that the said Identification

Card (I.D) was lost;

4. That I tried to locate said I.D but I could no longer find the same despite
exertion of earnest efforts. Hence, for all intents and purposes, said I.D is
considered lost;

5. The loss of said I.D was not due to any fraudulent or illicit purpose but due to
the circumstances afore-stated;

6. That I attest to the truth of the foregoing allegations and I am executing this
affidavit to appraise the concerned authorities, especially the ___________,
and in order that a new I.D be issued in my favor in lieu of the lost one.

IN WITNESS WHEREOF, I have hereunto set my hand this _____________ at

Davao City, Philippines.

________________
Affiant

SUBSCRIBED AND SWORN to before me this ______________, at Davao City,

Philippines. Affiant exhibited her his/her valid and competent SSS No. 09-0548200-8.

Doc. No. _______;

Page No. _______;
Book No. _______;
Series of 2023.