REPUBLIC OF THE PHILIPPINES )

CITY OF _______________ ) S.S.

AFFIDAVIT OF LOSS

KNOW ALL MEN BY THESE PRESENTS:

I, ______________________________, of legal age, Filipino, single, and a resident

of ____________________________________, after having been sworn in accordance with
law, hereby deposes and states the following:

1. I am a holder of a ____________________.

2. Sometime in _________________, I noticed that the said license is missing.

3. I exerted diligent efforts to locate the said item, however I could no longer locate
the same. Thus, I consider it lost for all legal intents and purposes.

4. I am executing this affidavit to attest to the truth of the foregoing and for
whatever legal purposes it may serve.

IN WITNESS HEREOF, I hereby affix my signature this _________________ in

_________________.

_________________
Affiant

SUBSCRIBED AND SWORN TO before me on the date and place indicated

above, the Affiant exhibited to me his _________________, valid until
_________________, as his competent evidence of identity, and known to me to be the
same person who executed the foregoing instrument and attested that the same is his
voluntary act and deed.

Doc. No. ___:

Page No. ___:
Book No. ___:
Series of 2020.