Republic of the Philippines)

_____________________ ) S.S.

AFFIDAVIT OF LOSS
I, _______________________, of legal age, Filipino citizen, and a
resident of ___________________________________________, Philippines,
after having been duly sworn to in accordance with law, do hereby depose
and state THAT:

1. I am the lawful holder of ________________________, issued by the

________________________________.

2. On __________________, the said ______________ was lost;

3. All my diligent efforts to locate the said ___________________ proved

futile; hence, I now consider the same as lost and beyond recovery;

4. The said ____________________ was never pledge or used to secure

any obligation;

5. I am executing this Affidavit to attest to the truth of the foregoing

statements and for all legal intents and purposes it may serve.

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

_______, 2020, _________________, Philippines.

____________________________
Affiant

SUBSCRIBED AND SWORN to before me on the date and place

indicated above. Affiant exhibited to me his/her ________________________.