REPUBLIC OF THE PHILIPPINES   )

CITY OF MAKATI ) S.S

AFFIDAVIT OF LOSS

           I NAME., Filipino, of legal age, married, and with office address __________________________, after
having been duly sworn to according to law hereby depose and state that:

1. I am the registered stockholder of the ________________ Corporation shares of stock covered

by the following stock certificates (the “Subject Stock Certificates”):

STOCKHOLDER NAME NO. OF

STOCK CERT. NO/S.
and ACCOUNT NUMBER SHARES

2. I have examined all my records and after diligent search, was unable to find the Subject
Stock Certificates. I believe the same were lost during the many times I moved residences when I was
living in ______________________ between ____________;

3. The Subject Stock Certificates have not been sold, pledged or in any way encumbered to
any third party in any manner whatsoever and as of this request, I remain to be the absolute owner
of the shares of stock covered by the Subject Stock Certificates, free from all liens and encumbrances.

4. I hereby agree to indemnify and hold the Issuer, ____________________ Corporation, their
respective stockholders, directors, officers, employees and representatives, as well as their assigns
and successors-in-interest, free and harmless from any and all losses, claims, suits, liabilities and/or
damages that the latter may incur as a result of or arising from my request for the replacement
and/or actual replacement of the Subject Stock Certificates.

5. In the event that the missing stock certificates are recovered, I shall immediately notify the
Corporation and/or the Issuer thereof and surrender the same to the latter.

6. I am executing this Affidavit to attest to the truth of the foregoing statements and to
request the Corporation and/or the Issuer to replace the Subject Stock Certificate(s) at my expense.

AFFIANT STATES NOTHING FURTHER.

           IN WITNESS WHEREOF, I have hereunto set my hand this ___day of _____________________, at the
City of Makati.

Affiant

SUBSCRIBED AND SWORN to before me, this _____________, by _____________ who exhibited to me his ID
No. _____________ issued at _____________, Philippines on ____________.
 
 
 
                                                                                    NOTARY PUBLIC
 
 
 
Doc. No.________;
Page No.________;
Book No.________;
Series No________;