Republic of the Philippines)

City of Iloilo ) s.s

x-------------------------------x

A F F I D A V I T OF L O S S

I, ________________, of legal age, married, Filipino Citizen, and a resident

of _________________, after having been duly sworn to according to law do
hereby depose and state:
1. That I am a holder of a ____________________ with
______________________;

2. That the aforesaid registration forms were lost from my possession;

3. That diligent search was made and undertaken to locate the aforesaid
registration forms but all my efforts proved futile and the registration
forms are now beyond recovery;

4. That I do declare that these registration forms are now lost for all
their legal effect and purpose;

5. That I am executing this affidavit to attest to the truth of all the

foregoing facts and to request for the issuance of new registration
forms from the ___________________________ for whatever legal purpose
it may serve best.

AFFIANT FURHTER SAYETH NAUGHT.

IN WITNESS WHEREOF, I have hereunto set my hand this

___________________, in the City of Iloilo, Philippines.

_____________________
Affiant

SUBSCRIBED AND SWORN to before me in the City of Iloilo,

Philippines this __________________ by _______________________ who
exhibited to me her _______________________ card with employee
number ___________________ and personally known to me, who is the
same person who personally signed before me the foregoing Affidavit of Loss
and acknowledged that she executed the same.

Doc. No._______;
Page No._______;
Book No._______;
Series of 2016.