Republic of the Philippines )

City of Iloilo ) SS.

x-----------------x

AFFIDAVIT OF LOSS

I, __________________, of legal age, married, Filipino and a resident

of ___________________, Philippines, after having been duly sworn to in
accordance with law do hereby depose and say:

1. That this is a the holder of ________________;

2. That sometime on __________________, I found out that our

______________ was misplaced and lost;

3. That we exerted earnest efforts to look for it but the same proved futile.
Thus, the same is now considered lost and beyond recovery;

4. That I am executing this affidavit to attest to the truth of the foregoing

statements and for whatever legal purpose it may serve.

IN WITNESS HEREOF, I have set my hand this ________ day of

_____________, 2017 in Iloilo City, Philippines.

___________________
Affiant
ID No. ________________
Issued by: _____________________

SUBSCRIBED AND SWORN to before me this _______ day of ____ 2017 in

Iloilo City, Philippines. Affiant exhibited to me his I.D. No. indicated above below
his name.

Doc. No. _________;

Page No. _________;
Book No. ________;
Series of 2017.