Republic of the Philippines)

Province of __________) S.c.

Municipality of _____ )

AFFIDAVIT OF LOSS DUE TO FIRE

I, _____________, 37 years of age, married,
_____________________________, after having duly sworn to in
accordance with law, do hereby depose and say that:

1. On December 28, 2019 our residence located at

____________________________ was burned and destroyed by fire;

2. As a result of the fire, our house was totally destroyed

or lost with an estimated damage of TWO MILLION PESOS (P2, 000,
000.00);

3. The fire that destroyed our residence was recorded by the

Bureau of Fire Protection. A certification concerning the fire is
hereto attached.

4. I am executing this affidavit to inform those concerned

about the loss and destruction of our residence and to the attest
to the truthfulness of the foregoing facts for whatever legal
purpose this may serve best.

IN WITNESS WHEREOF, I have hereunto set my hand this 9th day

of January 2020 in Wao, Lanao del Sur.

___________________
Affiant

SUBSCRIBED AND SWORN to before me this 9th day of January 2020

at Wao, Lanao del Sur, Philippines. Affiant having exhibited to me
her Voter’s ID with VIN: _____________________.