Republic of the Philippines)

City of Makati ) S.S.

AFFIDAVIT OF LOSS

I, ______________, Filipino, of legal age, single, and with

residence at _____________after being duly sworn to in
accordance with law, hereby depose and state that:

1. I am the owner of.

2. In the evening of was lost somewhere in

3. I diligently searched for the said items but failed to locate

them.

4. Given the manner in which the said items were lost, I could not
retrieve the same such that I now believe that they are now lost
beyond recovery.

5. As such, I am executing this Affidavit of Loss to attest to the

truth of the foregoing and in support of my request for the
replacement of

IN WITNESS WHEREOF, I have hereunto set my hand this 3rd day

of ______________at _____City, Philippines.

Affiant

SUBSCRIBED AND SWORN TO BEFORE ME, a notary public for and

in the City of Makati, affiant exhibited to me her _________ 12
September 2018.

Doc. No.____;
Page No. ___;
Book No. ___;
Series of 2018.