Republic of the Philippines)

______, Metro Manila )

AFFIDAVIT OF LOSS

I, (name), of legal age, Filipino, with residence address (address) after

having been sworn to in accordance with law, hereby depose and state that:

1. I am the holder of a/an (item), the particular details of which I can no

longer remember;

2. (insert circumstances of loss with date, time, and place);

3. Upon reaching home I realized that the said (item) is no longer in my

possession. I surmise that I must have dropped it somewhere or it must have
fallen out of my pocket while I was traversing the thoroughfares of Metro Manila
on the same day;

4. I exerted efforts to locate my (item) but all proved futile because I can
no longer locate the same. Hence, I declare the above-described (item) as
forever lost for all lawful intents and purposes; and

5. I execute this affidavit to prove the loss of my (item) for all legal
purposes this may serve.

IN WITNESS WHEREOF, I hereunto set my hand this (date) in (place)

(name)
Affiant

SUBSCRIBED AND SWORN to before me this (date) in (place), affiant

exhibiting to me her (I.D.) with number _____ as competent proof of her identity.

Administering Officer