REPUBLIC OF THE PHILIPPINES )

PROVINCE OF ________________ ) S.S.

CITY / MUNICIPALITY OF _________________)

AFFIDAVIT OF LOSS

I, ___________-, Filipino of legal age, and residing at _____________, after having been
sworn according to law, hereby depose and state that:

1. I am the owner of a ___________ with card no. __________ issued by ________.

2. On or about_________, I discovered the loss of the said _________ ID.

3. Despite diligent efforts, I could not find nor locate the same and I believe that it is
truly lost.

4. I am executing this affidavit for whatever legal purpose It may serve and to
request for a replacement of said ___________.

_____________________
<Name>
Affiant

SUBSCRIBED AND SWORN to before me this _____ day of ________, 2023 at

_____________, Affiant having exhibited to me his/her
______________________________ issued on __________ at _________.

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