REPUBLIC OF THE PHILIPPINES)PROVINCE OFBUKIDNON )ssCITY OF
VALENCIA )
AFFIDAVIT OF LOSS
I, _____________________________________ of legal age, single,
Filipino citizen, and a resident of
________________________________ after being sworn in accordance
with the law depose and say: 1.) I am a holder of a
__________________ issued by ______________________________;
2.) The foregoing __________________________ with I.D No.
0748463 was lost on _____________________ because
______________________;
3.) That despite diligent efforts has been exerted in order to
find and locate the said _____________________; the same could no
longer be found and proved to be beyond recovery;
4.) That this affidavit was executed to attest the truth of the
foregoing and for purposes of the re-issuance of a new
__________________ in my favor and whatever legal purposes it may
serve best.
IN WITNESS WHEREOF, I have here unto set my hand this 17th day
of January, 2013 in the City of Valencia, Province of Bukidnon.
__________________________ Affiant
SUBSCRIBED AND SWORN to before me this 18th day of January, 2013
at Valencia City, Province of Bukidnon.
NOTARY PUBLIC Doc No: ___ Page No: ___ Book No: ___Series of
___
