REPUBLIC OF THE PHILIPPINES)

PROVINCE OFBUKIDNON Jss

CITY OF VALENCIA )
AFFIDAVIT OF LOSS
L of legal age, single, Filipino
citizen, and a resident of after being
sworn in accordance with the law depose and say:
1) 1 am a holder of a issued by
2.) The foregoing with LD No. 0748463
was lost on because

3.) That despite diligent efforts has been exerted in order to find and locate
the said : the same could no longer be found
and proved to be beyond recovery:

4.) That this affidavit was executed to attest the truth of the foregoing and
for purposes of the re-issuance of a new
favor and whatever legal purposes it may serve best.

IN WITNESS WHEREOF. I have here unto set my hand this 17 day of January, 2013 in

the City of Valencia, Province of Bukidnon.

Affiant

SUBSCRIBED AND SWORN to before me this 18" day of January, 2013 at Valencia

City, Province of Bukidnon.

NOTARY PUBLIC

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