AFFIDAVIT OF LOSS

I, ____FULL NAME____, Filipino, of legal age, _____Status______, after having been

sworn to in accordance with law, do hereby depose and say:
1. That my deceased ___RELATION____, _____FULL NAME OF THE LESSEE_____,
entered into a Contract of Lease with the parish of Santuario de San Antonio for the lease of
niche contract no. _________ in Crypt __ at said parish;

2. That the document evidencing said Contract of Lease was issued with O/R No. ________
on _____DAY____, of _____MONTH_____ ____YEAR___;

3. That said document was lost under unknown circumstances at some point in time
between the beginning of said Contract of Lease the death of my ____RELATION TO THE
DECEASED LESSEE___ left behind at the time of his death;

4. That despite all due diligence in searching for said document, it was not found in the
papers my ___RELATION TO THE DECEASED___ left behind at the time of his death;

5. That I am executing this affidavit to attest to the truth of the aforementioned facts and to
request from the parish office of the Santuario de San Antonio a Certified True Copy of the
Contract of Lease.

IN WITNESS WHEREOF, I have hereunto set my hand this ___DAY__ of ___MONTH___,

___YEAR___ in the City of Makati, Metro Manila.

__________________
NAME OF REQUESTOR

SUBSCRIBED AND SWORN to before me, this ___DAY___ of ___MONTH___,

____YEAR___ in ___CITY___, with affiant exhibiting his __TYPE OF GOVERNMENT ID__
____ID NUMBER___,

Issued on _____DATE______ at ___PLACE___.

Doc. No. : ________;

Page No. : ________;
Book No. : ________;
Series of 20_____