This affidavit of loss was sworn by an individual on January 18, 2013 in Valencia City, Bukidnon. It states that some form of identification or document that was issued by an unnamed organization and with an identification number was lost on an unspecified date. Despite efforts to find the lost item, it remains missing and is considered unrecoverable. The affidavit was filed to confirm the truth of the loss and to request a new issuance of the lost item.

1. REPUBLIC OF THE PHILIPPINES)
PROVINCE OFBUKIDNON )ss
CITY 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
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