Republic of the Philippines}

Quezon City, Metro Manila} S.S.

AFFIDAVIT OF LOSS
(Child’s Record/Document)

I, ________________________________, Filipino, of legal age, single/married,

residing at ____________________________________________________________,
Bgy _____________________________, Quezon City, after having been duly sworn in
accordance with law, hereby depose and say:

1. That I am the mother/father/guardian of ______________________________

male/female, born on _________________________;

2. That the above child is a holder of a ________________________________

issued by the _______________________________________________ last
__________________;

3. That sometime last _______________ the above item/document was lost or

misplaced and that despite diligent efforts to find and locate the same, it was
never found and we have considered it lost since then due to excusable
negligence;

4. That the above item/document has not been found, exchanged, sold nor, in
any way, transferred to any person;

5. That it is my wish that the said lost item be replaced by the abovementioned
issuing office/institution/agency subject to its rules and regulations.

6. That I executed this affidavit to attest to the truth and veracity of the foregoing
facts and not for FRAUD and for whatever legal purpose it may serve.

AFFIANT FURTHER SAYS NONE.

IN WITNESS WHEREOF, I have hereunto set my hand this _______________

at Quezon City, Metro Manila, Philippines.

_________________________
Affiant
CTC No __________________
Issued on _________________
Issued at __________________

SUBSCRIBED AND SWORN to before me on the date and place above

indicated. Affiant exhibiting to me his/her Community Tax Certificate as indicated above.

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Series of 2010