Republic of the Philippines)

_____________________ ) s.s.

AFFIDAVIT OF LOSS
INSURANCE POLICY

I, Filipino, of legal age, and presently residing at _________________after having

been sworn to in accordance with law, do hereby depose and state that:

1. An insurance POLICY was issued by AAA INSURANCE ;

2. Unfortunately, I discovered that said policy was inadvertently misplaced/ lost.

3. In spite of all efforts to recover it, the same was nowhere to be found and should
therefore be considered lost.

I am executing this affidavit to attest to the truth of the foregoing.

.

Done this July ___, 2017 at the City of Manila, Philippines.

Affiant

SUBSCRIBED AND SWORN to before me this _________, at the City of Manila,

Philippines, affiant exhibiting to me her -8

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