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REPUBLIC OF THE PHILIPPINES)

QUEZON CITY ) S.S.

AFFIDAVIT OF LOSS

I, JUAN DELA CRUZ, Filipino, of legal age, and a resident of


_______________, Quezon City, after having been duly sworn in accordance
with law, hereby depose and say:

1. That I am a holder of Philippine Regulatory Commission (PRC)


Identification Card and a Driver’s License issued by the Land
Transportation Office;
2. That I used to put said idwentification cards in my wallet;
3. That sometime in December 2017, I took out my ATM Card from my
wallet and I noticed that my PRC ID and Driver’s License ID were
missing;
4. Despite diligent efforts to locate said identification cards, the same
proved futile;
5. That I am executing this affidavit to attest to the truth of the foregoing
facts and to request fo replacement of said identification cards.

IN WITNESS WHEREOF, I have hereunto affixed my signature this


____day of ____________ 2017 at ____________, Philippines.

JUAN DELA CRUZ


Affiant

SUBSCRIBED AND SWORN TO before me, a notary public in and for


_____________________ this ____ day of ____________ 2017. The affiant, whom I
identified through the following competent evidence of identity:_____________,
valid from______ to______ issued by_______________, personally signed
theforegoing 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 2017