AFFIDAVIT OF LOSS

REPUBLIC OF THE PHILIPPINES ]

CITY OF MANILA ] S.S.

I, _____________________________________, of legal age, Filipino, _________, and

residing at ___________________________________ Tondo, Manila, after having been duly
sworn in accordance with law, do hereby depose and state:

1. That I am the bona fide holder of ______________________________________

issued by the _______________________________;

2. That the said _____________________ issued to me was lost sometime

___________________________, due to
_____________________________________ ;

3. That said Certificate together with other important documents were carried
away by the flood and were all totally lost ;

4. That I am executing this Affidavit to attest to the truth and veracity of the
foregoing statements and for all legal intents and purposes this document may
serve.

IN WITNESS WHEREOF . I have hereunto set my hand and affixed my

signature on this 16th day of August in the City of Manila, Philippines.

___________________________________
Affiant

SUBSCRIBED AND SWORN TO before me on this ______ day of

__________ at Manila City Hall, affiant having exhibited to me his/her
_______________________
__________________________________ .

Doc. No.: ______;

Page No.: _______;
Book No.: _______;
Series of 2019.