AFFIDAVIT OF LOSS OF IDENTIFICATION CARD REPUBLIC OF THE PHILIPPINES ) _____________________________ ) SS.

I, (name of affiant), Filipino, of legal age, single/married to (name of spouse) , and a resident of (address of affiant), after having been duly sworn in accord ance with law, hereby depose and say: 1. That I am a holder of a school/company identification card bearing serial num ber (ID number) issued by (school/company name); 2. (State the circumstances leading to the loss of the ID, e.g.:) That I used to put said identification card in my pouch, among others; 3. That sometime on (date of loss), when I arrived home from work, I discovered that my school/company ID card was no longer in my pouch where I used to place i t; 4. That diligent effort to locate the same had pv 5. That said school/company ID card was not confiscated by the authorities of (s chool/company) by reason of any violation of school/company rules and regulation s; 6. That I am executing this affidavit to attest to the truth of the foregoing fa cts and to request for a replacement of said school/company ID card from (school /company name). IN WITNESS WHEREOF, I have hereunto affixed my signature this ____day of _______ _____ 20___ at ____________, Philippines. _________________________________ (Signature of Affiant over Printed Name)

SUBSCRIBED AND SWORN TO before me, a notary public in and for __________________ ___ this ____ day of ____________ 20___. The affiant, whom I identified through the following competent evidence of identity: (ID type and number), valid from ( date) to (date) issued by (issuing authority), personally signed the foregoing i nstrument before me and avowed under penalty of law to the whole truth of the co ntents of said instrument. Notary Public

Doc. No. ........; Page No. .......; Book No. .......; Series of 2010.