Sample Affidavit of Loss

This is a sample of an Affidavit of Loss, which you may need to make should you lose an item or document and desire its replacement. Note that the affidavit needs to be notarised by a Notary Public.

Republic of the Philippines                 )

Province of __________________            )

City/Municipality of ___________         ) S.S.

AFFIDAVIT OF LOSS

I, (name), Filipino, of legal age, (single/married/widow/widower), and a resident of ______________________, Philippines, after having been duly sworn in accordance with law, do hereby depose and state that:

  1. I am a bona fide holder/owner of (description of item lost);
  2. Sometime on ___________ in _____________, I was:

(describe the circumstances leading to the loss of the item)

  1. Despite my very best efforts and exercise of reasonable diligence to find the said property / item, I could not find the same such that I have good reason to believe the same is now lost and beyond recovery; and
  2. I am executing this affidavit in order to attest to the truthfulness and veracity of the foregoing and to facilitate the replace of the said lost item / property above-described.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of _____________ in _________________, Philippines.

SIGNATURE ABOVE NAME

(JURAT)

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