REPUBLIC OF THE PHILIPPINES ) Province/City__________________ ) SS.

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)___________; Example: 1. THAT on 28 February 2005 while riding on a jeepney on my way home, my wallet was pickpocketed without my knowledge; 2. THAT ___________________(describe the particulars of what was lost)_____; Example: 2. THAT my wallet contained my school ID, my Drivers License and some money bills;

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; Example: 3. THAT I exerted diligence efforts to locate my wallet or identify the culprit but to no avail and I therefore considered the same as lost and cannot 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, __________________. __________(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 2005. Wf00001 I hereunto affix my signature this _______________ at