Republic of the Philippines )

City/Municipality of ) S.S.

AFFIDAVIT OF LOSS

I, (name), Filipino, of legal age, (single/married/widow/widower), and a resident

of ______________________, Philippines, after having been duly sworn in accordance
with law, do hereby depose and state that:

1. I am a bona fide holder/owner of (description of item lost);

2. Sometime on ___________ in _____________, I was (describe the circumstances

leading to the loss of the item)

3. Despite my very best efforts and exercise of reasonable diligence to find the
said property / item, I could not find the same such that I have good reason to
believe the same is now lost and beyond recovery; and

4. I am executing this affidavit in order to attest to the truthfulness and veracity

of the foregoing and to facilitate the replace of the said lost item / property
above-described.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

_____________ in _________________, Philippines.

______________________________________
Affiant

JURAT

SUBSCRIBED and SWORN to before me this (date) at (City/Municipality), by

affiant who presented to me her _______________, with expiration date on
_______________.

Doc No:
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Series of 2023.