REPUBLIC OF THE PHILIPPINES )

PROVINCE OF ORIENTAL MINDORO ) S.S

CITY OF CALAPAN

AFFIDAVIT OF LOSS

That I, _______________________________________________________,
of legal age, Filipino, and residing at _____________________________________,
after having been duly sworn to in accordance with law, depose and say:

That I am holder of ______________________________________________

No.________________________________________________________________
Issued by: __________________________________________________________

That the aforesaid _______________________________________________

was lost in my possession on ___________________________________________
at _______________________________________________.

Those diligent efforts were executed to locate it but same proved futile.

That this affidavit is being executed so that a new one in my name with the
same efficacy and validity be issued.

IN WITNESS WHEREOF, I have hereunto signed this day of

, 2017 at Calapan City, Oriental Mindoro.

Affiant

SUBSCRIBED AND SWORN to before me this ___________ day of

________________________, 2017 at Calapan City, Oriental Mindoro.