Republic of the Philippines

Lipa City, Batangas

)
) S.S.

AFFIDAVIT OF LOSS
I, WILFRIDO ATIENZA, married, of legal age, Filipino, and with
residence at Amaia Scapes Subdivision, Brgy. Dagatan, Lipa City, Batangas,
having been duly sworn in accordance with law, hereby depose and state:
1. That I am a Professional Electrical Engineer (PEE) duly registered with
the Professional Regulation Commission (PRC) and was correspondingly
issued a PRC Identification Card (ID) with PEE No. 3179 dated May 18,
2000 and valid up to 2006;
2. That sometime in May of 2015, said PRC ID was discovered missing;
3. That despite diligent efforts in conducting an exhaustive search among
my properties and other personal effects to find the said PRC ID, the
same could no longer be located;
4. That said PRC ID was not confiscated nor surrendered to any person
and/or institution;
5. That considering the abovementioned premises, said PRC ID could now
be considered lost and beyond recovery; and
6. That I am executing this affidavit to attest to the truth of the foregoing
facts and to support my application for the renewal/reissuance of said
PRC ID before the concerned agency.
IN WITNESS WHEREOF, I have hereunto
____________ at _____________, Philippines.

set my hand

this

______________________________
WILFRIDO ATIENZA
Affiant
ID NO: SC 3364195 - 11/22/2004 - Quezon City
SUBSCRIBED AND SWORN to before me this ___ day of __________
20__ at _________________, with affiant exhibiting to me the aforementioned
government-issued ID as competent evidence of identity bearing his
photograph and signature in accordance with the 2004 Rules on Notarial
Practice.
Doc. No. _____;
Page No. _____;
Book No. _____;
Series of 20___.

NOTARY PUBLIC