REPUBLIC OF THE PHILIPPINES)

City of Calbayog, Samar ) S.S

AFFIDAVIT OF LOSS

I, ________________ , Filipino, of legal age, residing at _____________ , after having been sworn in
accordance with law hereby depose and state:

That I am the true and lawful owner of a certain _____________ which is more particularly
described as

That on ______

That on return

That upon inquiry and search the _________ is nowhere to be found;

IN WITNESS WHEREOF, I have hereunto set my hand this _____ day of ________________, 20__ at
Calbayog City, Samar.

___________________

Affiant

SUBSCRIBED AND SWORN TO before me, this ______ day of ____________, 20__ in Calbayog
City, Samar, with affiant exhibiting his valid identification card ___________________.