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REPUBLIC OF THE PHILIPPINES }

City of Surigao } S.S.


x-----------------------x

AFFIDAVIT OF LOSS

I, [NAME OF CARETAKER], Filipino, of legal age, and a resident of [ADDRESS], after


being duly sworn in accordance with law, depose and state that:

1 I am the caretaker of [NAME OF MINOR], Filipino, [AGE] years old, [GRADE]


Student of [SCHOOL] for the [SCHOOL YEAR];

2 [NAME OF MINOR] was issued an identification card, which she used to wear
everyday whenever she goes to school;

3 Yesterday, [NAME OF MINOR] complained to me that her identification card has


been misplaced;

4 As all efforts to find the same proved unrewarding, it is now safe to conclude that
recovery of the same is an impossibility;

5 Thus, I execute this affidavit for [NAME OF MINOR], as she is still a minor, to
establish its loss and to support her application for the issuance of identification
card.

IN WITNESS WHEREOF, I have hereunto set my hand this [CURRENT DATE] at


Surigao City.

[NAME OF CARETAKER]
Affiant

SUBSCRIBED AND SWORN to before me on the date and place indicated above, the
affiant exhibiting to me his [GOVERNMENT-ISSUED I.D. NUMBER], as competent proof of
identity.

NOTARY PUBLIC

Doc No. _____


Page No. _____
Book No. _____
Series of 2018