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    Affidavit of Loss Sample

    Uploaded by

    Dranreb Agurrab
    The affiant declares that they lost an item such as an ATM card or passport that was issued by a bank or government office. They describe when and how the item was lost despite efforts to find it. The affiant promises to surrender the item if found and requests a new one be issued, signing the document and swearing its contents are true.

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    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd

    Affidavit of Loss Sample

    Uploaded by

    Dranreb Agurrab
    434 views1 page
    The affiant declares that they lost an item such as an ATM card or passport that was issued by a bank or government office. They describe when and how the item was lost despite efforts to find it. The affiant promises to surrender the item if found and requests a new one be issued, signing the document and swearing its contents are true.

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    The affiant declares that they lost an item such as an ATM card or passport that was issued by a bank or government office. They describe when and how the item was lost despite efforts to find it. The affiant promises to surrender the item if found and requests a new one be issued, signing the document and swearing its contents are true.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    434 views1 page

    Affidavit of Loss Sample

    Uploaded by

    Dranreb Agurrab
    The affiant declares that they lost an item such as an ATM card or passport that was issued by a bank or government office. They describe when and how the item was lost despite efforts to find it. The affiant promises to surrender the item if found and requests a new one be issued, signing the document and swearing its contents are true.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
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    AFFIDAVIT OF LOSS

    I, ____________________________, of legal age, Filipino, single/married, and resident of ___________________________________________________, after being duly sworn according 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. 123456-7890, 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, I have hereunto set my hand 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 ______.

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