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 the owner and possessor of the following document issued under my name:

a. ________________________________________;
b. ________________________________________; and
c. ________________________________________.

2. That on ____________________, I tried to find the said documents in order to

____________________________ but was unable to find the same. After
exhausting all efforts in locating the same, I therefore concluded that such
documents were already lost.

3. I execute this affidavit to attest to the truth of the foregoing and for whatever legal
purpose it may serve best.

IN WITNESS WHEREOF, I have hereunto set my hand this _______ day of ________
20____ in the City of ____________________.

________________________________
Affiant