REPUBLIC OF THE PHILIPPINES

)Q U E Z O N C I T Y
) S S . I, _, Filipino, of legal age, and a resident of _, after
having beenduly sworn in accordance with law, hereby depose and say:1. That I am
a hol der of a voter s i dent i f i cat i on card i ssued byCommission of Elections
(COMELEC);2. That I used to put said identification card inside my wallet;3. That
sometime on April 20, 2011, when I arrived home fromwork, I discovered that
my voters ID card was no longer in my walletwhere I used to place it;4. That
diligent effort to locate the same had proved futile;5. That sai d I D card was not
conf i scat ed by the aut hori t i es or used in violation of the law;6. That I am
executing this affidavit to attest to the truth of thef oregoi ng f acts and t o
request f or a repl acement of sai d Voter s I Dcard from COMELEC.
IN WITNESS WHEREOF
, I have hereunto affixed my signaturethis ____day of ____________ 2011 at Quezon
City, Philippines.
SUBSCRIBED AND SWORN TO
before me, a notary public in and for _____________________ this ____ day of
____________ 20___. Theaffiant, whom I identified through the following competent
evidence of identity: (
ID type and number
), valid from (
date
) t o (
date
) issuedby (
issuing authority
), personally signed the foregoing instrumentbefore me and avowed under
penalty of law to the whole truth of thecontents of said instrument.
Notary Public
Doc. No. ........;Page No. .......;Book No. .......;Series of 2011.