Republic of the Philippines )

City of Kabankalan ) S.S.

x----------------------------------------x

AFFIDAVIT OF LOSS

I, ___________________________________________, of legal age,

single/married/widow/widower, Filipino citizen, and resident of
__________________________________________________, after having been duly sworn in
accordance with law, do hereby depose and say that:

1. I am a keeper of ________________________________________ duly issued by the

________________________________________ in the name of
___________________________________________;

2. I have recently discovered, however, that the said

________________________________________ is irretrievably lost and can no longer be found
despite diligent efforts to locate the same;

3. I am executing this Affidavit to attest to the truth of the foregoing statements,

and to request the agency or office concerned to issue a new
_____________________________________ in favor of _____________________________, in lieu of the
one that was lost;

IN WITNESS WHEREOF, I have hereunto set my hand this ______________________,

at Kabankalan City, Negros Occidental.

_________________________________________ Affiant

SUBSCRIBED AND SWORN to before me this ______________________, at Kabankalan

City, Negros Occidental. Affiant personally appeared before me, signed the foregoing
document in my presence, and attested under oath as to the truthfulness of the
allegations contained therein.