Republic of the Philippines)

City of Makati ) s.s.

AFFIDAVIT OF LOSS

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

_______________, after having been duly sworn in accordance with law, depose
and state that:

(1) I am a holder of an _______________ issued by ______________;

(2) I usually keep my ______________ inside my residence;

(3) On or about _______________, when I checked my files to look for my

_____________, I noticed that the ______________ was missing;

(4) All diligent efforts to locate the said _________________ proved futile;

(5) This affidavit of loss is being executed for the purpose of attesting to
the foregoing facts and for whatever legal purposes it may serve
including, but not limited to, the reissuance of the ______________.

IN TESTIMONY WHEREOF, I have hereunto set my hand this

_______________ at the ___________, Philippines.

Affiant

SUBSCRIBED AND SWORN to before me this __________________ affiant

exhibiting to me his valid identification _______________ issued on
_______________ and expiring on ____________.

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