AFFIDAVIT OF LOSS

I, ____________________, of legal age, Filipino, residing at

______________________________, after first being duly sworn, depose and say:

1. I am the custodian of the original stock certificates of

____________________________ with principal address at
___________________________ (hereinafter referred to as the “Corporation”);

2. That as custodian of the stock certificates of the Corporation, I had

possession of all the Corporation’s issued stock certificates;

3. That the above-mentioned stock certificates were lost/misplaced, or

inadvertently destroyed, and, notwithstanding earnest and diligent efforts by me
and my staff, we have not been able to locate the same;

4. That I am executing this affidavit for the re-issuance/ replacement

of the aforesaid stock certificates and for any legal intent and purpose it may
serve.

_____________________________
affiant

SUBSCRIBED AND SWORN to before me on this ____ day of

____________ 2018 in _____________; affiant exhibited to me his Philippine
___________________________ issued on ___________ at _______________.

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 2018.