Republic of the Philippines )

City of ) Sc

AFFIDAVIT OF LOSS

I, ________________________, of legal age, single, Filipino Citizen and residing

at _____________________________, after having sworn to in accordance with law deposes
and says that:

1. I am the owner of ____________________ issued by _________________.

2. That on or about _________________, I discovered the loss of the said

________________ under thre following circumstances;

_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________

3. That despite diligent efforts, I could not find nor locate the same and I believe that it
is truly lost

4. I am executing this affidavit for whatever legal purpose it may serve and to request
for replacement of the said ___________________.

IN WITNESS WHEREOF, I have hereunto set my hand at_______________,

_________this ____ Day Of ____, 20

_______________________
Affiant

Subscribed and sworn to before me this ___ day of _________, 2022 in Manila City, Philippines,
affiant exhibiting to me competent proof of his identity

Doc. No. _____

Page No. _____
Book No. _____
Series of 2022