AFFIDAVIT OF LOSS

I, , of legal age, Filipino citizen, and resident of , Philippines, after being

duly sworn in accordance with law, hereby depose and state under oath:

1. That I am the lawful owner/holder of the following lost item/document: .

2. That the lost item/document was in my possession and custody, and I have exercised due
care and diligence to keep it safe and secure.

3. That the said item was lost due to pickpocket, and I have made a diligent search and
inquiry to locate the lost item but to no avail. It is irretrievably lost and cannot be recovered.

4. That I am executing this Affidavit of Loss to attest to the truth of the foregoing facts and
for the purpose of applying for the issuance of a new/replacement item/document.

IN WITNESS WHEREOF, I have hereunto set my hand this ____ of ___________, ____, in
______________, Philippines.

Affiant

SUBSCRIBED AND SWORN to before me this ____ of _________, _____, in ____________,

Philippines, affiant exhibiting competent evidence of identity through ___________ with ID
number ___________, issued on _______________.

WITNESS MY HAND AND SEAL.

Notary Public
Doc. No. _____;
Page No. _____;
Book No. _____;
Series of 20___.