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Affidavit of Loss

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Jaja Fantilanan
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60 views1 page

Affidavit of Loss

Uploaded by

Jaja Fantilanan
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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REPUBLIC OF THE PHILIPPINES)

)S.S.
CITY OF ILOILO )
x----------------------------------------x

AFFIDAVIT OF LOSS

I, , Filipino, married and a resident of Iloilo City, Philippines, after having been
duly sworn to, in accordance with law, hereby depose and state, that;

I am a government employee, currently employed at Iloilo City. I am also a


member of a, a recognized employees’ union in

I availed a health insurance from a Health Maintenance Organization (HMO) as


provided in its Collective Negotiation Agreement;

I normally put my Identification Card inside my wallet. Recently I checked my


wallet but my ID card was nowhere to be found. Despite diligent efforts exerted to locate
the same, said identification card is now considered lost for all intents and purposes;

I am executing this affidavit to attest to the truth of the foregoing and to establish
the fact of loss of my School Identification Card and in support of my request for the
issuance of a new one.

IN TRUTH WHEREOF, I have hereunto set my hand this ____________day of


August 2015 in the City of Iloilo, Philippines.

Affiant

JURAT/NOTARIAL CERTIFICATE

The affiant, whose name and personal circumstances are stated above,
personally appeared before me this _____________in Iloilo City, presented the
foregoing affidavit signed the same in my presence and affirmed under oath to the
correctness of the contents or allegations of the same.
The affiant is personally known to me and was personally identified by me by
way of a competent evidence of identity known as

WITNESS MY HAND and NOTARIAL SEAL, at the place and on the date above-
written.
Doc. No. ____;
Page No.____;
Book No. ____;
Series of 2015.

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