Republic of the Philippines)

City of Cagayan de Oro ) S.S.

Affidavit of Loss

I, ____________________, of legal age and a resident of _____________,

under oath declare that:

1. ________________________________________________________

2. ________________________________________________________

3. ________________________________________________________

4. I am executing this sworn statement, to ___________________________

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

of _______________, 2018 in the City of Cagayan de Oro.

Affiant
ID No. __________

SUBSCRIBED AND SWORN to before me, in the City of Cagayan de Oro, this
_____ day of _______________, 2018.

Doc No. _____;

Page No. _____;
Book No. _____;
Series of 2018.