AFFIDAVIT OF LOSS

REPUBLIC OF THE PHILIPPINES)

TARLAC CITY ) S.S.

I, _________________________, Filipino, of legal age, single/married/widowed,

and a resident of __________________________________, after having duly sworn in
accordance with law, hereby depose and say that:

1. I am in possession of/the holder of the following:

____________________ with the following details:

2. Sometime in/on _____________________, I discovered/realized that I had

lost the above ______________________.

3. I have exerted all efforts to find the above but it has proven to be fruitless,
hence, I have no choice to but to consider the same as irretrievably lost.

4. The loss of my ___________________________ was solely by reason of my

misplacing them and not because it was confiscated by authorities due to
violation of any law, rule and/or regulation.

5. I am executing this affidavit to attest to the truth of the foregoing facts to allow
me to have replacement/s for the above lost items if needed and for whatever
legal purpose it may serve.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ______________ at

Tarlac City, Philippines.

Affiant

SUBSCRIBED AND SWORN to before me in Tarlac City this __________________ by

___________________________ personally known to me who is the same person who
personally signed before me the foregoing Affidavit of Loss and acknowledged that he
executed the same.