Affidavit of Loss

Company Letterhead

{{company_name}}

{{company_address}}

Phone: {{phone}}

Email: {{email}}

Website: {{website}}

AFFIDAVIT OF LOSS

I, {{full_name}}, of legal age, {{civil_status}}, a resident of {{address}}, after being sworn in accordance with law, depose and state that:

1. I am the lawful owner of the {{description_of_lost_item_or_document}}.

Circumstances of Loss

2. On or about {{date_of_loss}}, at approximately {{time_of_loss}}, I discovered that the aforementioned {{description_of_lost_item_or_document}} was lost under the following circumstances: {{detailed_circumstances_of_loss}}.

3. I have exerted diligent efforts to locate the said {{description_of_lost_item_or_document}} but to no avail. The item/document is truly lost and cannot be recovered.

Declaration of Fact

4. I am executing this Affidavit to attest to the truth of the foregoing facts and for the purpose of {{purpose_of_affidavit, e.g., applying for a replacement, record-keeping}}.

No Encumbrances

5. The lost {{description_of_lost_item_or_document}} is not encumbered, pledged, or used as collateral for any loan or obligation at the time of its loss.

Undertaking for Falsehood

6. I understand that any false statement made in this affidavit may subject me to legal penalties for perjury.

Signature Block

IN WITNESS WHEREOF, I have hereunto set my hand this {{day}} day of {{month}}, {{year}} in {{city}}, {{country}}.

_____________________________

{{full_name_of_affiant}}

Affiant

ID Number: {{affiant_id_number}}

Issued on: {{id_issue_date}}

Issued at: {{id_issue_place}}

SUBSCRIBED AND SWORN to before me this {{day}} day of {{month}}, {{year}} in {{city}}, {{country}}. Affiant exhibited to me his/her competent evidence of identity as indicated above.

_____________________________

NOTARY PUBLIC

My Commission Expires: {{notary_commission_expiry_date}}

Roll No.: {{notary_roll_number}}

PTR No.: {{notary_ptr_number}}

IBP No.: {{notary_ibp_number}}