REPUBLIC OF THE PHILIPPINES )

CITY OF __________________ ) S.S.

AFFIDAVIT OF LOSS

I, __________________, a Filipino citizen of legal age, residing at

_____________________________ after being sworn to in accordance with law,
depose and say that:

1. That I am an Employee of _____________________________;

2. That I applied for cash advances to be used for a particular activity,
____________________________
3. The amount of the cheque was ____________________________;
4. On ______________________, when I was about to proceed to
______________________________________
5. I suddenly realized that the cheque were no longer in my possession.
6. That despite diligent search and efforts to locate the same, I could not find
them such that I now believe that they are now lost beyond recovery;
7. As such, I am executing this affidavit to attest to the truth of the foregoing
facts and to support my application for the issuance of a check in lieu of
the one that was lost.

IN WITNESS WHEREOF, I have hereunto set my hands this

_____________________ in Muntinlupa City, Philippines.

_____________________
Affiant

SUBSCRIBED AND SWORN TO before me this

_____________________ in Muntinlupa City, Philippines, affiant exhibiting
to me her competent evidence of identity indicated below her printed
name, bearing her picture and signature appearing therein.

Doc No. _______;

Page No. ______;
Book No. ______;
Series of _______;