Fillable Printable Sample Affidavit of Loss
Fillable Printable Sample Affidavit of Loss
Sample Affidavit of Loss
AFFIDAVIT OF LOSS
I, ____________________________, of legal age,Filipino, single/married,andresident of
___________________________________________________, after beingduly swornaccording to law,
hereby depose and state that:
1. I am the [holder / custodian / registered owner] of [Describe here the item/document/paper
lost including Serial No., if any (Example: Passbook No. 12345, ATM Card No. 12345678, Credit Card No. 123-
456-7890, Passport No. AA123456)] issued by the [Insert Name of Issuing Company / Office / Department
(Example: Banco de Oro, Department of Foreign Affairs, etc.)] on [date of issuance] at [place of issuance, if
any].
2. Sometime in [State here approximate time (i.e. day/month/year) of loss], I lost the above
[Insert name of item/document/paper] under the following circumstances:
[Here briefly narrate how the item, document or paper got lost or was probably lost]
3. Despite diligent efforts exerted, I could no longer locate, find or recover the said[Insert name
of item/document/paper], and to the best of my knowledge, the same is truly lost.
4. The said [Insert name of item/document/paper] has not been confiscated by any officer of the
law or the issuing office or agency due to the violation of any law, statute, order, rule or regulation.
5. In the event that the lost [Insert name of item/document/paper]should hereafter be found or
located, I undertake to forward or surrender the same to [Insert Name of Issuing Company / Office /
Department] for appropriate disposal.
6. I am executing this Affidavit to attest to the truth of the foregoing statements and to request
the issuance of a new [Insert name of item/document/paper] in lieu of the one which was lost.
AFFIANT FURTHER SAYETH NAUGHT.
IN WITNESS WHEREOF, Ihave hereunto set myhand this ____________________ at
_________________________.
[Signature above Printed Name of Affiant]
Affiant
SUBSCRIBED AND SWORN to before me this ____________________, affiant exhibited to me
his/her Competent Evidence of Identity by way of __________________ issued at ______________ on
__________________.
Doc. No. ______;
Page No. ______;
Book No. ______;
Series of ______.
