Simple affidavit of loss

Date Published:
Republic of the Philippines )
City of Manila ) S.S.

AFFIDAVIT OF LOSS

I, JUAN X. DELA CRUZ, of legal age and a resident of 123 Kanto Street, Barangay 123, City of Manila, Philippines, under oath, avers that:
  1. I was issued a company identification (ID) card by my employer, ABC Corporation;
  2. I usually kept said ID in my bag on my way home or on my way to work;
  3. On January 15, 2020, my bag was robbed away from me while I was about to board a jeep on my way to work; and
  4. I am executing this, as required, to get replacement for said lost ID.
Signed on January 16, 2020 in the City of Manila.

(Signed)
JUAN X. DELA CRUZ
Affiant

SUBSCRIBED and SWORN to me on January 17, 2020. Affiant showed to me his SSS ID with number 123-456-789.

ATTY. PROJECT X. JURISPRUDENCE
Notary Public for the City of Manila
123 Bahay Street, Barangay 345, City of Manila
Notarial Commission No, 123, until December 31, 2020
IBP-Manila No. 123456; January 15, 2019
PTR-Manila No. 123456; January 15, 2019
Roll No. 123456; April 30, 2014
MCLE No. II. 123456; September 8, 2018
MCLE No. II. 987654; September 8, 2018
Serial No. of Commission: M-123

Doc. No. ___;
Page. No. ___;
Book No. ___;
Series of 2020.