REPUBLIC OF THE PHILIPPINES)

) S.S.

AFFIDAVIT OF LOSS

I, _________________________, of legal age, Filipino, and resident of

________________________________________, after having been duly sworn in
accordance with law, hereby depose and state:

1. That sometime January 2021, I acquired

___________________________;

2. As such, I was issued by Certificate of Registration

________________________;

3. That sometime _____________________, I could not locate and

find the same;

4. That despite diligent efforts has been exerted in order to find,

locate, and retrieve said claim stub; the same could no longer be
found and proved to be beyond recovery;

5. That this affidavit was executed to attest the truth of the

foregoing and for purposes of claiming the purchased watch and
whatever legal purposes it may serve best.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

__________________________ at _______________________, Philippines.

__________________________________
Affiant

SUBSCRIBED AND SWORN to before me, a notary public this ___ day of
________________ in __________________________, affiant personally came and
appeared with his competent proof of identity in the form of his
____________________________, bearing his photograph and signature, known to me
and to me known to be as the same person who personally signed the foregoing
instrument before me and avowed under penalty of law to the whole truth of the
contents of said instrument.

Doc. No. ____;

Page No. ____;
Book No. ____;
Series of 2021.