REPUBLIC OF THE PHILIPPINES )

ANGELES CITY ) S.S.

AFFIDAVIT OF LOSS
I, Juan Dela Cruz of legal age, Filipino citizen, single and a resident of Philippines, after
having been duly sworn in accordance with law, depose and state:

1. That I was issued a Company ID by MANILA;

2. That I placed my Company ID in the pocket of my pants;

3. That sometime in the December 19, 2055 I tried to locate the said Company ID from my
pocket, but I was not able to find it anymore, and seemed to have dropped it in the
vicinity of Philippines;

4. That I exerted diligent efforts to locate my missing Company ID card but all my efforts
have been in vain as I failed to locate it up to the present;

5. That for all intents and purposes, my missing Company ID is now considered lost and
beyond hope of recovery;

6. That I executed this Affidavit of Loss to affirm all the foregoing facts and in compliance
to the requirement of MANILA for the replacement of the Company ID.

IN WITNESS WHEREOF, I have hereunto affixed my signature on this 3 RD day of

January, 2056 at Angeles City, Pampanga.

JUAN DELA CRUZ

Affiant

SUBSCRIBED AND SWORN to before me on this 3 rd day of January 2056 at Angeles

City, Pampanga. Affiant exhibiting to me his TIN ID #111-111-111 issued on December 29,
2055.