Republic of the Philippines)

______________ ) S.S.

AFFIDAVIT OF LOSS

I, ___________________, Filipino, of legal age, single/married, with office address at

__________________________________, after having been sworn to in accordance with
law, do hereby depose and state as follows:

1. I am the _____________________________________ in the Philippines.

2. That pertinent to _____________________________ sometime in 2016.

3. I submitted the _________________ for the processing of the aforementioned

__________________ with the relevant government office. Unfortunately,
sometime in 2017, the said __________________ was subsequently lost.

4. Despite diligent efforts exerted, I could no longer locate, find or recover the said
______________________, and to the best of my knowledge, the same is truly lost.

5. In the event that the lost _________________________ should hereafter be found

or located, I undertake to forward or surrender the same to ________________ for
appropriate disposal.

I am executing this Affidavit to attest to the truth of the foregoing statements.

AFFIANT FURTHER SAYETH NAUGHT.

IN WITNESS WHEREOF, I have hereunto set my hand this __ January 2018 at

_________________.

___________________________

SUBSCRIBED AND SWORN to before me this ____________________,, affiant

exhibited to me his Driver’s License with No. ____________ as his competent evidence
of identity issued at ________________ on ____________________.
Doc. No.
Page No.
Book No.
Series of 2018.