REPUBLIC OF THE PHILIPPINES )

CITY AND PROVINCE OF ___________ ) S.S

x-------------------------------x

AFFIDAVIT OF LOSS

I, (AFFIANT’S FULL NAME), of legal age, Filipino and a resident of (Affiant’s

complete address), Philippines, after having been duly sworn to in accordance with
law, do hereby depose and say that:

1. (State that you are the owner or holder of the document, ID, Certificate of Title
for transfer, or things that you lost, and the office, agency, institution, or
person who issued the same, see the example of a lost Driver’s License)I am
the owner of a Driver’s License duly issued by the Land Transportation Office
(LTO) and registered in my name;
2. (State the place or circumstance which you normally kept the said object
which was lost)I have usually kept the same license inside my wallet and
brings with me wherever I go;
3. (State how you lost the object)Few weeks ago, I went to ______ City to buy
some stuffs however upon arrival at my destination, I noticed that I lost my
wallet including my Driver’s License;
4. (If applicable, state your effort/s to find the lost object and the reason why it
cannot be found)I tried to look for the same traversing back my path wherein I
could possibly dropped my wallet and asked some people along the way but
despite my efforts of finding the wallet, my search for it and my hopes of
finding the same proved futile;
5. (Your declaration that the object was lost and beyond recovery)Because of
this, I declared the same to be lost and cannot be found; and
6. (The purpose on why you executed this affidavit which commonly includes to
replace the same)I am executing this Affidavit in order to attest to the truth of
the foregoing facts and for other legal purpose(s) this may serve best.
IN WITNESS WHEREOF, I have hereunto set my hand this __(Date)________at
________City, Philippines.

(Signed)JUAN DELA CRUZ

Affiant

The affiant, whose name and personal circumstances are stated above,
personally appeared before me this __________ in the City/Province of _______,
Philippines, presented the foregoing affidavit, signed the same in my presence and
affirmed under oath to the correctness of the contents or allegations of the same.
The affiant was identified by competent evidence of identity, namely a (must
be a Government issued ID) bearing his photograph and signature.
WITNESS MY HAND AND SEAL on the place and date above-mentioned.

Doc. No. ____;

Page No. ____;
Book No. ____;
Series of 202_.