REPUBLIC OF THE PHILIPPINES )

___________________)S.S.

AFFIDAVIT OF LOSS

I, ____________________________, Filipino, of legal age, and a resident

of ____________________________________________, after having been duly
sworn in accordance with law, hereby depose and state that:

1. I am the owner of ________________

2. I have recently discovered that the said item irretrievably lost and can
no longer be found despite diligent efforts to locate the same;
 
3. This affidavit is being executed to attest to the truthfulness of the
foregoing statements and for all intent and legal purposes it may serve.

IN WITNESS WHEREOF, I have hereunto set my hands this _____ day of

_____________ 20____ at ________________

___________________________
Affiant

SUBSCRIBED AND SWORN to before me this _____ day of

__________________ 20____ at ____________