AFFIDAVIT OF LOSS

I, (name)_______________, of legal age and residing/with address at

_________________________________________, under oath, state:

1. THAT on (date)___________ at (place)__________________ while

(describe how loss occurred)_________________________________________
________________________________________________________________;

2. THAT(describe the particulars of what was lost)________________

_________________________________________________________________;

3. THAT I exerted diligent efforts to locate (the thing lost)______________ or but to

no avail, and I, therefore, considered the same as lost and can no longer be found;

4. THAT I am executing this Affidavit to attest to the truth of the foregoing facts and
to use the same for whatever legal purpose it may serve.

IN WITNESS WHEREOF, I hereunto affix my signature this __________ at _________.

(name)__________________
Affiant

SUBSCRIBED AND SWORN to before me this _______________ at

__________________, Affiant exhibiting to me his Community Tax Certificate bearing
No. ________________ issued at _________________ on ______________________.

Doc No. ________;

Page No. _______ ;
Book No. _______;
Series of _______.