Affidavit of Loss - Template, Sample Form to Fill out Pro · PH-law

REPUBLIC OF THE PHILIPPINES  )
________, ________ ) S.S.

AFFIDAVIT OF LOSS

I, ________, of legal age, Filipino, ________, and a resident of ________, after having been duly sworn to in accordance with law, do hereby depose and state THAT:

1. I am the registered owner and lawful holder of a School Identification Card (the “School ID”) bearing Student Number ________, issued by ________ located at ________;

2. On or about ________, I discovered the loss of the said School ID under the following circumstances:

________;

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4. The loss of the said School ID was not due to any fraudulent intent or design on my part, and the same has not been pledged, assigned, surrendered, or otherwise disposed of by me to any person or entity;

5. I am executing this Affidavit to attest to the truth of the foregoing statements, to formally report the loss of the said School ID, and to support my application for the issuance of a replacement thereof;

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IN WITNESS WHEREOF, I have hereunto affixed my signature this ________ day of ________, 20____, at ________, Philippines.

________
Affiant

________
Competent Evidence of Identity

SUBSCRIBED AND SWORN TO before me this ________ day of ________, 20____, at the City/Municipality of ________, Province of ________, by the affiant, ________, who is personally known to me or who exhibited to me the following competent evidence of identity: ________, and who I am satisfied is the person who personally signed the foregoing instrument and acknowledged before me that the same is his/her free and voluntary act and deed, executed in accordance with the 2004 Rules on Notarial Practice.

________
NOTARY PUBLIC

Doc. No.: ________;
Page No.: ________;
Book No.: ________;
Series of ________.