Republic of the Philippines)

City of __________ ) Ss.

AFFIDAVIT OF LOSS

I, _________________, Filipino, of legal age, single and a resident

of _____________________, after having been duly sworn in accordance
with law, hereby depose and say that:

1. That I am a government employee and was issued a TIN Card with

assigned TIN number:__________;
2. That said TIN Card was misplaced and despite diligent efforts
exerted to find it, the same just proved futile and is now beyond recovery;
3. That I execute this affidavit to attest to the veracity and
truthfulness of the foregoing statements and as a requirement in my request
for the replacement of said TIN Card from the Bureau of Internal Revenue.

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

day of _______________, in the ___________________.

___________________
Affiant

SUBSCRIBED AND SWORN to before me this ___________ in

_____________________.