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REPUBLIC OF THE PHILIPPINES ) QUEZON CITY ) SS.

I, _, Filipino, of legal age, and a resident of _, after having been duly sworn in accordance with law, hereby depose and say: 1. That I am a holder of a voters identification card issued by Commission 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 from work, I discovered that my voters ID card was no longer in my wallet where I used to place it; 4. That diligent effort to locate the same had proved futile; 5. That said ID card was not confiscated by the authorities or used in violation of the law; 6. That I am executing this affidavit to attest to the truth of the foregoing facts and to request for a replacement of said Voters ID card from COMELEC.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ____day of ____________ 2011 at Quezon City, Philippines.

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 instrument before me and avowed under penalty of law to the whole truth of the contents of said instrument. Notary Public

Doc. No. ........; Page No. .......; Book No. .......; Series of 2011.

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