REPUBLIC OF THE PHILIPPINES)

CITY OF MAKATI)S.S.

AFFIDAVIT OF LOSS

I, <name> Filipino, of legal age, <civil status> and with <home address>, after having duly
sworn to in accordance with law, depose and state:

1. That I used to be part of <name of insurance company>, a corporation duly

organized and existing under and by virtue of the laws of the Republic of the
Philippines;

2. That as being part of <name of insurance company> I was given by ID and PR

booklet;

3. That I have recently discovered that the said ID and PR Booklet is irretrievably lost
and can no longer be found despite diligent efforts to locate the same;

4. As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
and for whatever legal purpose that this may serve.

IN WITNESS WHEREOF, I have hereunto affixed my signature this _______ day of ___________
in the <resident address> Philippines.

<name>
Affiant

SUBSCRIBED AND SWORN to before me this _______________in the

___________________________ The affiant whom I identified through the following
competent evidence of identity: ____________________________________________, valid
from ___________________ issued at ______________________________, personally signed
the foregoing instrument before me and avowed under penalty of law to the whole truth of the
contents of said instrument.

Notary Public

Doc. No. ________;

Page No. ________;
Book No.___________;
Series of 20___