REPUBLIC OF THE PHILIPPINES)

Province of ________
) S.S.
City of ____________
)
x------------------------x
AFFIDAVIT OF LOSS
I, ________________________, of legal age, American national, married and a resident
of ______________________after being duly sworn in accordance with law, depose and state:
1. That I am a bonafide holder of Alien Certificate of Registration Identity Card (ACR ICard) No. ___________________ issued by the Bureau of Immigration of the Republic
of the Philippines;
2. That the said ACR I-Card was kept in my wallet together with my other pertinent
identifications;
3. That on ______________________, I noticed that my said ACR I - Card was nowhere to
be found, believing it might have been misplaced somewhere else or might have slipped
out of from my wallet during my travels;
4. That I exerted utmost efforts to locate my said ACR I-Card, in places where it may
possibly misplaced or been dropped but my efforts only prove futile, such now that I
believe it was already lost beyond recovery;
5. That my ACR I-Card has never been confiscated by any government agency / office /
department / bureau for some unlawful acts whatsoever;
6. As such, I am executing this Affidavit to attest to the truth of the foregoing, to inform the
Bureau of Immigration about the loss of my ACR I Card and to support my request to
issue a new ACR I-Card in lieu of the one that is lost, for whatever legal purposes that
this may serve.
IN WITNESS WHEREOF, I have hereunto set my hand this day of ___________ at
Roxas City, Capiz, Philippines.
______________________
Affiant
ID No: _______________
Issued by: ____________

SUBSCRIBED AND SWORN to before me this day of ____________ at Roxas City,

Capiz by affiant who is personally known to me and further exhibited her competent
identification as shown above.