Affidavit of Loss

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I, of legal age, Filipino citizen, and resident of , , 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 I have made a diligent search and inquiry to locate the lost item/document but to no avail. It is irretrievably lost and cannot be recovered.
4. That the loss of the said item/document was not due to any negligence, willful act, or omission on my part.
5. 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 , .
________________________


SUBSCRIBED AND SWORN to me this _____ of ____________, __________, in _____________, ________, 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 _____.

Actual Printout

I,
of legal age, Filipino citizen, and resident of
,
, 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 I have made a diligent search and inquiry to locate the lost item/document but to no avail. It is irretrievably lost and cannot be recovered.
4. That the loss of the said item/document was not due to any negligence, willful act, or omission on my part.
5. 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
,
.
________________________


SUBSCRIBED AND SWORN to me this _____ of ____________, __________, in _____________, ________, 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 _____.