Republic of the Philippines)

Province of Cotabato )s.s

Municipality of Carmen )

AFFIDAVIT OF LOSS

I, __________________________________, of legal age, single/married, Filipino

and a resident of _____________________________________________ after having
been duly sworn in accordance with law do hereby depose and say:

1. That I am a holder of _______________________________ issued by

____________________________________________________________
___________________________________________________________;

2. That I have discovered that said ______________________ was no longer

in the place where I have kept it;

3. That despite diligent efforts in locating said ______________________

the same could no longer be located;

4. That said ______________________ was not confiscated nor encumbered

by any lawful authority but was really lost;

5. That I am executing this affidavit to attest to the truth of all the foregoing
statements and for whatever legal purpose it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this

________________________ 2019 at Carmen, Cotabato, Philippines.

______________________________
Affiant

SUBSCRIBED AND SWORN to before me this ______________________

2019 at Carmen, Cotabato, Philippines.

Doc. No. _____; JOSEPH N. MADRIAGA

Page No. _____; Notary Public
Book No. _____; Until December 31, 2019
Series of 2019. Roll of Attorneys No. 71479;
PTR No. 8814076/07-25-18
IBP O.R. No. 1170/07-18-18