REPUBLIC OF THE PHILIPPINES )

City of _____________________
)
AFFIDAVIT OF LOSS
I, ________________, Filipino, of legal age and a resident of ____________________, after
having been duly sworn in accordance with law, hereby depose and state that:
1. I am an employee of ______________________;
2. On ______________ 2014 at around seven (7) in the evening, while
__________________________________, I noticed that my wallet and I.D.s
which I usually place in my bag are missing;
3. Inside my wallet are the following:
a.
b.
c.
d.
e.
f.

Company I.D. and Company Access Card

Voters I.D.
TIN I.D.
IHealth Card
ATM Card
Library Card

4. I believe that they are now lost beyond recovery because despite diligent
search and efforts to locate and retrieve the said cards, the same proved
futile and unavailing;
5. The cards in my bag have not in whole or in part, been assigned, transferred
or otherwise disposed of in any manner whatsoever;
6. As such, I am executing this Affidavit of Loss to attest to the truth of the
foregoing and to comply with the requirements for the issuance of new
Identification Cards and block the ATM account from possible cash
withdrawal by others.
IN WITNESS WHEREOF, I have hereunto set my hand this ___ of September 2014 at
____________________ Philippines.

________________________
____________
Affiant
SUBSCRIBED ANS SWORN to before me this ___ day of September 2014, in
______________, with affiant exhibiting to me his ___________________________ valid
until __________________.
NOTARY PUBLIC
Doc. No.:
Page No.:
Book No.:
Series of 2014.