I, _________________________________________, of legal age, _________, Filipino citizen,
and residing at __________________________________________________________________________, after being sworn to before the law depose and state:
1. That I was issued a ________________________________________, issued by the
_____________________________, which expires on ______________________. 2. That I used to keep the said __________________________ in ___________________________ for safekeeping. 3. That unfortunately on ___________________, the said ____________________________ was mutilated_____________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ ________________________________________________________________________________________. 4. That I am now executing this affidavit to prove the facts mentioned above and for all intents and purposes necessary.
IN WITNESS WHEREOF, I hereby set my hand this ____ day of __________________,
20___ at ________________________________________.
SUBSCRIBED AND SWORN to before me this ____ day of __________________ 20___ at
_______________________________________ by __________________________________ presenting his/her _____________________________________ issued by _________________________________ and valid until __________________.