REPUBLIC OF THE PHILIPPINES )

CITY OF XXXXXXXXXX ) S.S.

AFFIDAVIT OF LOSS

I, XXXXXXXXXXXX, of legal age, Filipino, single, and with residence

address at XXXXXXXXXXXXXXXXXXXXXXX, after having been duly sworn to
in accordance with law, do hereby depose and say that:

1. I am a holder of a Company Identification Card with ID No.

XXXXXXXXXXXXXXXX;

2. Said identification card was in my possession on XXXXXXXXXXXXXX

and the same was lost while I was in XXXXXXXXXXXXXXXXXXX;

3. Despite diligent efforts, the said identification card could no longer be

located. Thus, I consider it lost and beyond recovery;

4. I am executing this affidavit in order to attest to the truth and veracity of

the foregoing facts for whatever legal purpose this may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this

XXXXXXXXXXXXXX, XXXXXXXXX in XXXXXXXXXXXXXXXXXXXXXX.

XXXXXXXXXXXXXXXXXXXX
AFFIANT
Driver’s License No.
XXXXXXXXXXXXX

SUBSCRIBED AND SWORN to before me this XXXXXXXXXXXXXXx in

XXXXXXXXXXXXXXXXXXXXXX, affiant exhibiting to me his competent
evidence of identity stated above.