AFFIDAVIT OF LOSS

REPUBLIC OF THE PHILIPPINES)

_____________________________ ) S.S.

I, ___________, Filipino, of legal age, residing at _____________, after having been sworn in
accordance with law hereby depose and state:

1. That sometime in ____________, I was on the way home from work,

when I was held up by an armed man, who took my bag, wallet and
cellphone.

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

IN WITNESS WHEREOF, I have hereunto set my hand this ________at _________________________.

___________

SUBSCRIBED AND SWORN to before me, this ____ day of ______________, 20___ in
___________________ City, with affiant exhibiting his CTC No. _______________ ,
Issued on ______________________ at _________________________.

NOTARY PUBLIC
Until December 31, 201___

Doc. No. : ________;

Page No. : ________;
Book No. : ________;
Series of 20_______.