Republic of the Philippines )

Capas, Tarlac ) S. S.

AFFIDAVIT OF LOSS

I, _________________________, of legal age, Filipino and a resident

of____________________________, after being duly sworn to in accordance with
law, hereby depose and state;

1 That I was issued/the owner/in possession of the following:

_____________________________________________________________
_____________________________________________________________
______________________________________________________

2 That I usually kept the aforesaid document/s in ______________________

_____________________________________________________________

3 _____________________________________________________________
________________________________________________________

4 That I exerted all efforts to locate the same, but despite such efforts, I could
no longer find said documents/s was/were lost;
5 That I therefore execute this affidavit to declare the fact of loss of the
aforesaid document/s in order to exolain the circumtances on how it
was/were lost for the purpose on inducing the concerned office/s and/ or
bank/s to issue me the same in lieu of the loss ones and for whatever legal
purpose it may serve;
6 That I attest to the truthfulness and veracity of the foregoing statements
having been made own personal knowledge and belief.

IN WITNESS WHEREOF, I have hereunto set our hands this ______ day
at the Municipality of Capas, Province of Tarlac, Philippines.

____________________
Affiant

SUBSCRIBED AND SWORN TO before me this ______ day of October,

2016, at the Municipality of Capas, Province of Tarlac, Philippines.
Doc. No. _______;
Page No. _______;
Book No. _______;
Series of _______.