REPUBLIC OF THE PHILIPPINES)

_____________________________)S.S.

AFFIDAVIT OF LOSS

I, __________________________, of legal age, Filipino Citizen and residing at

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

1. That I am the holder of __________________________________;

2. That unfortunately, the aforesaid _______________ which was in my possession

has been lost and/or misplaced and despite diligent effort made to look for it, the
can no longer be recovered;

3. That I am executing this affidavit to attest to the truth of the foregoing facts and
for whatever legal purposes it may serve.

Affiant further sayeth naught.

IN WITNESS WHEREOF, I hereunto affixed my signature this

_________________________ at ____________________________.

______________________
Affiant

BEFORE ME, a Notary Public in and for ____________________ this

_____________________________ personally appeared _______________________ who
has satisfactory proved to me his identity through his Identification Card indicated
below his name, that he is the same person who executed and voluntarily signed the
forgoing Affidavit of Loss.

Doc. No. ____ ;

Page No. ____ ;
Book No. ____ ;
Series of 2017.