REPUBLIC OF THE PHILIPPINES)

_____________ ) S.S.

AFFIDAVIT OF LOSS

I, ______________ (NAME), of legal age, Filipino and a resident of

___________________ (ADDRESS) after having been sworn in accordance with law,
depose and state:

1. I am the holder of a valid Philippine ________ (ID);

2. Said ______ (ID) and official receipt were misplaced/lost;

3. That said ___________ (ID) and official receipt could not be located despite my
diligent efforts to look for them;

4. That I am executing this affidavit to attest to the truth of the foregoing and for the
purpose of securing another Philippine ____________ (ID)

IN WITNESS WHEREOF, I have hereunto set my hand this ____ day of

________ (DATE) in ______ (PLACE)

________________
Affiant

SUBSCRIBED AND SWORN TO before me this ___ day of ____________

(MONTH AND YEAR) in __________ (PLACE), affiant having exhibited to me his
________ (ID). __________ issued at ____________________ on _____________.

Doc. No. _____

Page No. _____
Book No. _____
Series of _____