REPUBLIC OF THE PHILIPPINES )

CITY OF _____________________________) s.s

AFFIDAVIT OF LOSS

I, _____________________________, , of legal age, Filipino, married, with residence address

at 316 Plain St. Block 27, Lot 77, Ai-Ai, General Tinio, GMA, Cavite, subscribing under oath,
hereby depose and state:

1. That I am the holder of the _____________________________;

2. That sometime in _______________________________, I discovered that

____________________________ was probably lost, misplaced, or destroyed;

3. Despite diligent search and efforts to locate the said _____________________, I could not
fins the same such that I now believe that it is now lost or beyond recovery;

4. That I am executing this statement to attest to the above facts, and to prove to
________________________ that I lost the _______________________________ and the request for
the replacement of the _____________________________.

IN WITNESS WHEREOF, I have hereunto set my hand this ______________ at Quezon

City.

_____________________________________
CARL MIRANDA SALAZAR
Affiant

SUBSCRIBED AND SWORN to before me this _____ day of __________ at

________________________. I HEREBY CERTIFY that I have personally examined the herein
offended party and I am satisfied that they voluntarily executed and understood their given
affidavit.

Doc. No._________;
Page No. _________;
Book No.__________;
Series of 2023.