REPUBLIC OF THE PHILIPPINES)

______________________ ) S.S.

AFFIDAVIT OF LOSS
I, ____________________, Filipino, of legal age, single and a resident of
___________________________________________, after having sworn to in accordance with
law, hereby depose and say that:
(1) That I am a holder of _______________________ bearing card number
________________________ issued by ______________________;
(2) That I used to put said card in my wallet;
(3) That sometime on _________________, I lost my wallet when I rode a bus going to Manila
during which the said above card is one of the content of the said wallet;
(4) Diligent search of said card and wallet with the bus company proved futile and unavailing;
(5) I am executing this affidavit to comply with the requirements of ____________ for the re-
issue of said ___________________.
Affiant further sayeth naught.

SUBSCRIBED AND SWORN TO before me this day of ________________

in_____________________ affiant exhibiting to his _______________________________
issued on ________________ at _________________.

Doc. No. ____;

Page No. ____;
Book No. ____;
Series of