Republic of the Philippines )

City of Metro Manila ) S.S.

AFFIDAVIT OF LOSS
(OF COMPANY IDENTIFICATION CARD)

I, ___________, of legal age, Filipino, single, and a resident of

_________________, after having been duly sworn to in accordance with law,
hereby depose and state THAT:

1) I was issued a Company Identification Card by ___________;

2) On ____________, I lost my wallet, including my ID from __________;

3) I took great pains to look for the said ID but to no avail;

4) Despite diligent search and efforts to locate the said ID, I could not find
the same such that I now believe that it is now lost beyond recovery;

5) I am executing this Affidavit of Loss to attest to the truth of the foregoing

and to support the application for the issuance of new one in lieu of the one
which was lost.

IN WITNESS WHEREOF, I have hereunto set my hand this ___ day of _____
_____ at ________ City, Metro Manila, Philippines.

_______________________________________

Affiant

SUBSCRIBED AND SWORN TO before me this ___ day of ___ _____ in

_______ City, Metro Manila, Philippines, affiant exhibiting to me his _______ ID,
with number ___________, bearing his name and signature.