REPUBLIC OF THE PHILIPPINES)
CITY OF _____________________) Sc.
x------------------------------------------x
AFFIDAVIT
I, ___________________, Filipino, of legal age, single and a resident of
___________________, after being duly sworn to in accordance with law, depose and
state that:
1. As a _____________, I was issued a ____________ with No. ____________;
2. On or about ____________, I discovered that my said __________ was missing
and I exerted all efforts to locate the same but I could no longer find it;
3. Said _______________ has not been confiscated by any officer of the law or by
the officers of ______________ for violation of any law, ordinance, decree or the
rules and regulations of ______________;
4. As all diligent search and efforts to find the same proved futile, it is now safe to
assume that said ____________ is now lost beyond recovery;
5. As such, I execute this affidavit to attest to the truth of the foregoing facts, to
support my application for the issuance of a new _____________, and for
whatever legal purpose that this affidavit may serve;
6. FURTHER AFFIANT SAYETH NAUGHT.
IN WITNESS WHEREOF, I have hereunto set my hand this _______________
in the City of ______________, Philippines.
_____________________________
AFFIANT
SUBSCRIBED and sworn to before me on the date and place first above written
by the above-named Affiant whom I have identified through his _______________
which is valid until ________________.
NOTARY PUBLIC
Doc. No. _____;
Page No. _____;
Book No._____;
Series of 20___.