AFFIDAVIT OF LOSS

REPUBLIC OF THE PHILIPPINES ]

CITY OF MANILA ] S.S.

I, __________________, of legal age, Filipino, with residential address at

_________________________________, after being sworn in accordance with law,
do hereby depose and say THAT:

1. I am an employee of _______________________________, a corporation duly

organized under existing Philippine laws, with business address at
____________________________________, and with the position of
_____________ in said company. As such, I have the custody of all funds,
monies and checks of said company in relation to its business transactions;
2. In connection with the company’s business transactions, _______________ had
received a _________________, with Check No. ___________, dated
__________;
3. On ______________ or thereabouts, I was carrying said check along with other
documents in my folder. Upon arrival in ___________ office, I checked said
folder. However, I discovered that the above check was missing and was not
inside the folder;
4. After due and diligent search of said check, I am unable to find the same and all
efforts in locating said check proved futile;
5. Thus, I am hereby executing this Affidavit to apprise the truth of such loss and in
order to secure a replacement of said check; and
6. I have executed this Affidavit to attest to the truth of the foregoing statements and
that such are made willingly and voluntarily, free from duress, force, threat,
intimidation, or undue influence and with full knowledge of my rights under the
law.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ______

day of January, __________, at Manila, Philippines.

____________________________
Name of Affiant

SUBSCRIBED AND SWORN to before me this ______ day of January,

__________. Affiant exhibited to me her ID No. _______________, issued on
________________, issued at _______________.

NOTARY PUBLIC

Doc. No. ____________;

Page No. ____________;
Book No. ___________;
Series of 20____.