Republic of the Philippines )

________________ City . . . . . . . .)s.s

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

AFFIDAVIT

I, __________________________, of legal age, Filipino, single/married, and with postal

address at ____________________________________, Philippines, after having been sworn, depose
and state:

1. That I am the holder and keeper of the following documents:

a. ___________________________
b. ___________________________
c. ___________________________
d. ___________________________
e. ___________________________
f. ___________________________
2. That I usually kept the said documents in _______________________;

3. Last ___________________________, I discovered that said documents as mentioned

above were lost from my files and I cannot recall whether I took it or I misplaced
it somewhere else;

4. That upon knowing that it was missing, I exerted diligent effort to locate the said
documents but the same proved be futile, for such reason, I am declaring said
documents to be lost for all intents and purposes;

5. That the said documents were not confiscated by any government agency nor
used as a consideration for any unlawful purpose;

6. That I execute this affidavit to attest to the truthfulness of the foregoing

statements for the purpose of ____________________________________________________ issue
another copy of the said documents in lieu of the lost one and whatever legal
purpose or purposes this may serve.

IN WITNESS WHEREOF, I have hereunto set my hand and affixed my signature this
_________________________ at _____________________________, Philippines.

_________________________________
Affiant

SUBSCRIBED AND SWORN TO BEFORE ME, a notary public in and for City of
____________________, Philippines, this _________________________.

Doc. No._____
Page No._____
Book No._____
Series of 2018.