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AFFIDAVIT OF LOSS
I, name, of legal age, Filipino, single/married and a resident of address, after having been
duly sworn to in accordance with law, depose and state THAT:
1.
2.
3.
That the Official Receipt while in possession of an agent was misplaced and could no
longer be located in spite of diligent efforts to locate it;
4.
5.
Said document was not confiscated by any government authorities for violation of R.A.
4136 and other related laws;
6.
____________________
Affiant
SUBCRIBED
AND
SWORN
TO before
me
this ___________________ in
by
way
of
on __________________.
Doc. No. _____;
Page No. _____;
Book No. _____;
Series of 20__.
__________________
issued
at
______________