REPUBLIC OF THE PHILIPPINES)

Province/City__________________ ) S.S.

AFFIDAVIT OF LOSS

I, ________(name)_______, of legal age and residing/with address at

____________________,
under oath, state:

1. THAT on ______(date)_____ at _________(place) _________ while

_________ (describe how loss occurred) ___________;

2. THAT ___________________(describe the particulars of what was lost)_____;

3. THAT I exerted diligent efforts to locate _____(the thing lost)____ or but to no

avail and I therefore considered the same as lost and can no longer be found;

4. THAT I am executing this Affidavit to attest to the truth of the foregoing facts
and to use the same for whatever legal purpose it may serve.

IN WITNESS WHEREOF, I hereunto affix my signature this _______________ at

__________________.

______________
____
Affiant

SUBSCRIBED and SWORN TO before me on the date and at the place indicated
below. The affiant exhibited to me his competent evidence of identity as indicated above.

Signed this ______________at ________________, ______________________,

Philippines.

WITNESS MY HAND AND SEAL.

Notary Public

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