Republic of the Philippines

)
____________________
) S.S.
____________________
)

AFFIDAVIT OF LOSS
I, __________________________, of legal age, Filipino, and a resident of
____________________________________, after having been sworn in accordance with
law, hereby depose and state:
1. That I am the same person executing this affidavit;
2. That I am an issuant of a Pay Slip dated ____________________ duly issued
by the _______________________________;
3. That I regularly keep the abovesaid Pay Slip inside my wallet;
4. That however on _______________________________, 2016, to my shock and
surprise, I noticed that the aforementioned Pay Slip was no longer
contained inside my wallet hence I exerted my best effort to locate the
same, but all my efforts were in vain;
5. That the above-mentioned Pay Slip is now considered lost and beyond
recovery;
6. That I am executing this affidavit to attest to the truth of the foregoing
and for whatever lawful purpose that it may serve.
IN WITNESS WHEREOF, I have hereunto set my hand this ___ day of
_________, 2016 at ____________________________.

________________________
Affiant
ID No. _____________
Issued by: __________
Issued on: __________

SUBSCRIBED AND SWORN to before me this ____ day of ________, 2016 at

________________________.

Doc. No. ______

Page No. ______
Book No. _____
Series of 2016