REPUBLIC OF THE PHILIPPINES) S.

S
City of Ozamiz……………………. )

AFFIDAVIT OF LOSS

I, __________________, of legal age, single, Filipino and

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

1. That I was issued __________________________ by

_________________________.

2. That said _______________ has always been in my possession since

then until lately when I found out the same to be missing;

3. That I exerted earnest effort in order to recover and/or locate the

same, but my effort is to no avail;

4. That I am executing this affidavit to attest the true fact of the loss of
the above-described documents.

IN WITNESS WHEREOF, I hereunto affix my signature this _____ h day

of ____________ in Ozamiz City, Philippines.

________________________
Affiant

SUBSCRIBED AND SWORN to before me this ___________________, in

_________, Philippines.