REPUBLIC OF THE PHILIPPINES )

______________,) S.S.

AFFIDAVIT OF LOSS

I, _______________________, of legal age, single, a resident of

____________________________, being duly sworn, depose and state that;

1. I am the owner of the ____________________________;

2. I exerted utmost effort to find said documents but all proved futile. Hence, I now
consider it lost and beyond recovery;

3. I have never sold, pawned, swapped, exchanged or given the aforesaid items in
exchange for any consideration, neither the same have confiscated by the authorities;

4. This affidavit is executed to make a formal report of the fact of loss of the aforesaid item
and to request for the replacement of the same.

IN WITNESS WHEREOF, I have hereunto affixed my signature at the place and on the
date mentioned in the Jurat.

________________________
Affiant (Name and Signature)

SUBSCRIBED AND SWORN TO before this day of _________ in _____________. Affiant is

personally known to the Notary Public and/or exhibited his/her proof of identity:
___________________ until ___________ .

Doc. No. _________

Page No. _________
Book No. _________
Series of 2020