REPUBLIC OF THE PHILIPPINES )

QUEZON CITY, METRO MANILA) S.S.

AFFIDAVIT OF LOSS

I, _________________, of legal age, Filipino, ______ and with residence and

postal address at _________________________________
_________________________________after having been duly sworn to in
accordance with law, do hereby deposes and states:

1. That I am

2. That on the day of

3. That I walked from

4. That I have acquired a Certified True Copy of my

_____________________________________ attached here as Annex
A;

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

foregoing and for all intents this might be of legal worth.

Affiant further sayeth naught.

IN WITNESS WHEREOF, I have hereunto set my hands and affixed my

signature on this _____ day of ______________ _______, in Quezon City, Metro
Manila.

_____________________
Affiant

SUBSCRIBED AND SWORN to before me on the same date and place

above-written. Affiant ______________________ exhibited to me his
____________________ with number ______________________ issued
on___________________ at ________ City.

Doc. No. ______;

Page No. ______;
Book No. ______;
Series of ________.