REQUEST FOR ISSUANCE OF AFFIDAVIT OF LOSS

Company (SRSI,
Date Requested:
SRMI, AJAI etc.):
Department: Date Needed:

Requested By:

Department Head:

Detailed Description of the event of loss (If it involves property/vehicle, state its particulars)

Name and Address of the Affiant:

ID to be presented by the Affiant: (Include ID no. and attach a copy)

To whom will it be submitted: To whom will the property be issued (if

applicable):

Number of Copies Required:

NOTE:

Date when the Secretary’s Certificate is needed should not be less than five days from the date a proper request
is made unless it is urgent. If it is urgent, reason why it is urgent.