REPUBLIC OF THE PHILIPPINES)

CITY
OF KABANKALAN ) S.S.
x - - - - - - - - - - - - - - - - - - ---- - - - -x

AFFIDAVIT OF LOSS
I, ___________________________________ ______ year old, Filipino, single/married
and a resident of ______________________________________________________,
after having been duly sworn to in accordance with law, do hereby depose and say:
That I am a holder of ______________________________________ duly issued by the
_____________________________________________________;
That the said ___________________________________ was lost in my possession and
its whereabouts could not be ascertained despite diligent efforts having been exerted.
That I am executing this affidavit to attest to the truth of the foregoing statements and to
request the agency/office concerned to issue a new _________________________ in lieu of the
one that was lost.
IN WITNESS WHEREOF, I have hereunto set my hand this
__________________, 2013, at Kabankalan City, Negros Occidental, Philippines.

_____day

_____________________________
Signature over printed name
CTC No. _____________________
Issued at _____________________
Issued on ____________________
Contact No. ___________________

SUBSCRIBED AND SWORN to before me this _____ day of _______________ 2013,

Kabankalan City, Philippines. Affiant exhibited to me his/her Community Tax Certificate as
above-stated and his/her _____________________ ID/License with No. _________________, as
proof of Identity. I hereby certify that I have personally examined the affiant, and I am satisfied
that he/she voluntarily executed and understood the allegations stated in his/her affidavit.