SAMPLE FORM OF AFFIDAVIT OF LOSS

 

REPUBLIC OF THE PHILIPPINES )

MAKATI CITY                                   ) SS.

 

AFFIDAVIT OF LOSS

 

I, JUAN Z. REYES, of legal age, and with address at XXXXXXXXXX, under oath, state:

 

     1. THAT  I have a Citibank Mastercard bearing No. _____ and expiring  on _______ .

 

  1. THAT on XXXXX at around 5:30 PM I boarded a bus bound for Quezon City;

 

  1. THAT after I got off at corner EDSA and Quezon Avenue, I discovered that my wallet containing my aforesaid Citibank Mastercard was gone;

                                                                  

  1. THAT I exerted diligent effort to locate the same but to no avail and thus I consider my Citibank Mastercard as lost and can no longer be found;

 

  1. 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 XXXXXXX at Makati City.

 

 

JUAN Z. REYES

Affiant

 

SUBSCRIBED AND SWORN to before me this XXXXXX at Makati City, Affiant exhibiting to me his competent proof of identity bearing his picture and signature as described below:


NAME TYPE OF ID. NUMBER DATE AND PLACE OF ISSUANCE/ EXPIRY DATE.
 

JUAN Z.

REYES

 

 PASSPORT  XXXX  

ISSUED ON XXXX AT XXXX AND EXPIRING ON XXXX.

 


Doc. No. _____;

Page No. _____;

Book No. _____;

Series of ______.