REPUBLIC OF THE PHILIPPINES)

CITY OF SURIGAO ) S.S.

AFFIDAVIT OF LOSS

I, _________________, of legal age, Filipino citizen, resident

___________________________ after having been duly sworn to in accordance with
law, do hereby depose and say:

1. That I am a holder of a BAPTISMAL CERTIFICATE of my late husband

_________________ duly issued by the church of Iglecia Filipina Independente (IFI);

2. That the above-mentioned BAPTISMAL CERTIFICATE was in my

possession until I found out that the same is missing;

3. That the afore-cited BAPTISMAL CERTIFICATE was lost and beyond

recovery;

4. That despite of earnest efforts to locate it, the same proved futile;

5. That I am executing this affidavit to attests to the truth of the foregoing

circumstance and for whatever legal purpose this may serve best.

IN WITNESS WHEREOF, I have hereunto set my hand and affix my signature

this _____________ at __________, Philippines.

______________________
(Affiant)

SUBCRIBED AND SWORN to before me this ________________ at

_____________, Philippines. I hereby certify that I have personally examined the affiant
and that she understands the foregoing statements and executed the affidavit freely and
voluntarily.