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Affidavit of Loss

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AFFIDAVIT OF LOSS

KNOW ALL MEN BY THESE PRESENTS:

I, __________________________ of legal age, Filipino, single/married, and a resident of


________________________________________________, after having been sworn in accordance
with law, hereby deposes and states the following:

1. I am holder/owner/ or possessor of the following identification card / document:


_____________________________

2. I have recently discovered the said item/s is/are irretrievably lost and can no longer be found
despite diligent efforts to locate the same;

3. I execute this affidavit to attest to the truth of the foregoing.

MARK C. GOMEZ
PRESIDENT

REPUBLIC OF THE PHILIPPINES)


BACOLOD CITY ) S.S.

SUBSCRIBE AND SWORN, to before me this , 2019 at Bacolod City, Negros Occidental.
Affiant exhibited to me his valid CRN with ID No. 0111-0291418-7 as competent proof of identity.

NOTARY PUBLIC

Doc No: ________;


Page No: ________;
Book No: _______;
Series of 2019 ;

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