REPUBLIC OF THE PHILIPPINES ) _____________________________ ) SS.

AFFIDAVIT OF LOSS OF IDENTIFICATION CARD I, _______________(name of affiant)_____________, Filipino, of legal age, single/married to ____________________________(name of spouse)__________________, and a resident of ____________________(address of affiant)______________, after having been duly sworn in accordance with law, hereby depose and say: 1. That I am a holder of a [school]/[company] identification card bearing ID number _____(ID number)_____ issued by [Name of School]/[Name of Company]; 2. That I used to put said ID Card in my ID necklace and hang it on my neck; 3. {When it probably got loss} That sometime on ____(date of loss)____, when I arrived home from work, I discovered that my [school]/[company] ID card including my ID necklace was no longer hanging on my neck; 4. {Where it probably got loss} That ________________________________________; 5. {How it probably got lost} That __________________________________________; 6. That diligent effort to locate and search in places where I have been on that day, said ID was nowhere to be found; 7. That said school/company ID card was not confiscated by the authorities of [school]/ [company] by any reason. Neither I violated any [school]/[company] rules and regulations; 8. That I am executing this affidavit to attest to the truth of the foregoing facts and to request for a replacement of said school/company ID card from [school]/[company name]. IN WITNESS WHEREOF, I have hereunto affixed my signature this ____th day of ____________ 20___ at _______________, Philippines.

_________________________________ (Signature of Affiant over Printed Name)

SUBSCRIBED AND SWORN TO BEFORE ME, a notary public in and for _________(City/Province)____________ this ____th day of ____________ 20___. Affiant personally came and appeared with _____________(Competent Evidence of Identity)______ issued by the _________(Government Agency)______ on ___(date)__ at ________(place)_________, bearing his photograph and signature, known to me as the same person who personally signed the foregoing instrument before me and avowed under penalty of law to the whole truth of the contents of said instrument.

Doc. No. ____ Page No. ____ Book No. ____ Series of 20__

Atty ___________________________________________ Notary Public Commission Serial No. ____________________________ Notary Public for _______(Province/City)______________ Until December 31, 20__ Office: ______________(address)____________________ Roll No. __________ IBP Lifetime Roll No. _________; __/__/__ ; _(Province)_ PTR No. _________ ; __/__/__ ; _(Province)_ MCLE Compliance Cert. No. __________; __/__/__