REPUBLIC OF THE PHILIPPINES )
PROVINCE OF DAVAO DEL SUR ) S. S.
CITY OF DIGOS )
X-----------------------------------------/
AFFIDAVIT OF LOSS
I, -______________________________________, of legal age, single, married,
widow/widower, Filipin and a resident of __________________________________________,
Philippines after having been duly sworn to in accordance with the law, hereby depose and say:
That I am the same and identical person who caused execution of this affidavit;
That I am a member/bonafide holder of a _____________________________________
Issued by___________________________________________sometimes in________________.
That the said _____________________________________________________________
Was lost or missing while in my possession;
That diligent efforts were exerted to locate my__________________________________
but the same yielded negative result;
That I am executing this affidavit of loss in order to apprise the authorities concerned
and to attest to the truthfulness of the foregoing statements, and for whatever legal intent and
purpose this may serve.
IN WITNESS WHEREOF, I have hereunto set my hand this ______day of __________
at Digos City, Davao del Sur, Philippines.
____________________________________
Affiant
SUBSCRIBED AND SWORN to before me this__________________day of ________
at Digos City, Davao del Sur ,Philippines.