Affidavit of Loss


Below is an example of an Affidavit of Loss for your personal use. No redistribution of this document is allowed without our permission. You may edit the lost items as necessary.

REPUBLIC OF THE  PHILIPPINES )

Province/City__________________  ) SS.

AFFIDAVIT OF LOSS

I, ________(name)_______, of legal age and residing/with address at _________________________________________,  under oath, state:

1.                 THAT on ______(date)_____ at _________(place)_________ while _________(describe how loss occurred)___________;

Example:

“1.     THAT on 28 February 2005 while riding on a jeepney on my way home, my wallet was pick-pocketed without my knowledge; “

2.                 THAT ___________________(describe the particulars of what was lost)_____;

Example:

“2.     THAT my wallet contained my school ID, my Driver’s License and some money bills;

3.       THAT I exerted diligent efforts to locate _____(the thing lost)____ or but to no avail and I therefore considered the same as lost and can no longer be found;

Example:

“3.     THAT I exerted diligence efforts to locate my wallet or identify the culprit but to no avail and I therefore considered the same as lost and cannot be found;

4.       THAT I am executing this Affidavit to attest to the truth of the foregoing facts and to use the same for whatever legal purpose it may serve.

IN WITNESS WHEREOF, I hereunto affix my signature this _______________  at __________________.

__________(name)________

Affiant

SUBSCRIBED AND SWORN to before me this _______________ at __________________, Affiant exhibiting to me his Community Tax Certificate bearing No. ________________ issued at _________________ on ___________________________.

Doc No. ________;

Page No. _______ ;

Book No. _______;

Series of 2005.

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