REPUBLIC OF THE PHILIPPINES)

CITY OF ) S.S.
x----------------------------------x

AFFIDAVIT OF LOSS

I, ____________, of legal age, Chinese, a resident of___________, after

having been duly sworn to in accordance with law, depose and state THAT:

1. On November 27, 2017, I was issued a Special Resident Retiree’s Visa with
_____________by the Bureau of Immigration;

2. Recently, I had tried to look for the said printed Special Resident Retiree’s Visa
but the same could not be found;

3. Despite diligent search and efforts to locate the said Special Resident Retiree’s
Visa, I could not find the same such that I believe that it is now lost beyond
recovery;

4. As such, I am executing this affidavit to attest to the foregoing facts and to

support the application for the issuance of a new one in lieu of the one which
was lost.

IN WITNESS WHEREOF, I have hereunto set my hand

this ___________________ in, Pasay City, Philippines.

____________________

Affiant

SRRV No. ___M-047498______

SUBCRIBED AND SWORN TO before me this ___________________ in

_________________, Philippines, affiant exhibiting to me his valid proof of
identification.

Doc. No. _____;

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