REPUBLIC OF THE PHILIPPINES)

MANDALUYONG CITY………….) S.S

AFFIDAVIT OF LOSS

I, _________________________, of legal age, Filipino, single, and with

residence at _____________________________, do hereby depose and state
that:

1. I previously have my _________________ Identification Card No.

_____________ issued by the ____________________________ in my custody;

2. Sometime in ___________________, I lost the said Identification

Card in _____________ when I was _________________________;

3. Despite diligent efforts exerted, I could no longer locate, find or

recover the said Certificate of Registration, and to the best of my knowledge, the
same is truly lost;

4. The afore-mentioned Identification Card has not been confiscated by

any officer of the law or the issuing office or agency due to the violation of any law,
statute, order, rule or regulation

5. In the event that the lost Identification Card should hereafter be found
or located, I undertake to forward or surrender the same to the appropriate office
for disposal; and

5. I am executing this Affidavit to attest to the truth of the foregoing

statements and to request the issuance of a new Identification Card in lieu of the
one which was lost.

AFFIANT FURTHER SAYETH NAUGHT.

IN WITNESS WHEREOF, I have unto set my hand this ____ day of

____________ 2019 in Mandaluyong City.

______________________________
Affiant

SUBSCRIBED AND SWORN TO before me, this ___ day of __________

2019, affiant exhibiting to me his I.D. ______________________.

Doc No.____:
Page No.____;
Book No.____:
Series of 2019.