Legal Forms Prelim Exam

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Republic of the Philippines )

Balagtas, Bulacan ) Sc

AFFIDAVIT OF LOSS

I, AMROSI D. BANSAO, of legal age, Filipino, single and a resident of


Springville Heights, Alabang, after having been sworn to in accordance
with law, hereby depose and state, that:

1. I am a holder/owner/ or possessor of the following identification


card/ document: BSU Identification Card; SSS ID; and a Driver’s License;

2. I have recently discovered the said item/s is/are irretrievably lost


and can no longer be found despite diligent efforts to locate the same;

3. I am executing this affidavit to attest to the authenticity of the


foregoing facts in accordance with law.

WITNESS MY HAND this 15 day of august 2017 in Balagtas, Bulacan.

AMROSI D. BANSAO
Affiant
(Signature over Printed Name)
Competent Evidence of Identity
ID No. :
issued on:
at:

SUBSCRIBED and SWORN TO before me on the date and at the place


indicated below. The affiant exhibited to me his competent evidence of
identity as indicated above. Signed this, 15 day of Augiust in Balagtas,
Bulacan, Philippines.

Doc No. 914; MA. THERESA S. CRUZ-DAGUNA


Page No. 890; Notary Public
Book No. X11; Until December 31, 2017
Series of 2017 PTR No. 7032531/Malolos City, Bulacan/01-03-17
IBP No. 852316/01-03-17
MCLE Compliance No. 1120014144
Roll No. 40038

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