Republic of the Philippines)

City of Tagbilaran           ) S.S.

AFFIDAVIT OF LOSS

I, JAMES M. AYENTO, Filipino, of legal age, single, and a resident of

Pobalcion, Danao, Bohol, Philippines, after being duly sworn to in accordance
with law, do hereby depose and state:

1. That I am a holder/owner and possessor of Master’s Declaration of

Safe Departure (MDSD) and Crew List for the month of December
2018 and January 2020 which was issued by PMI;

2. That on or about November 3, 2021, the MDSD and Crew List was
lost and its whereabouts cannot be ascertained despite due and
diligent search made and undertaken such that I now believe that the
same is lost beyond recovery;

3. That I now request the PMI to issue a new MDSD and Crew List in
lieu of the lost one and I bind myself to surrender the lost MDSD and
Crew List in the event that the same is found and/or located;

4. That I covenant to indemnify the PMI for any loss and damage it
may incur by reason of its issuance or replacement;

5. That I am executing this affidavit to attest to the veracity of the

above-stated facts, for the purpose of the issuance of a library card
or any other legal purpose which this affidavit may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this

_______________ at Tagbilaran City, Philippines.

JAMES M. AYENTO
Affiant

SUBSCRIBED AND SWORN TO BEFORE ME this __________ affiant

personally presented to me his competent and valid proof of identity.

Doc No. _____;

Page No. _____;
Book No. _____;
Series of 2022