Republic of the Philippines

)
Province of ______________
) S. S.
Municipality of ________________ )
x----------------------------------------x
AFFIDAVIT

OF

LOSS

I, __________________________, of legal age, Filipino and a resident of

_____________________________, after having been duly sworn to in accordance
with law, hereby depose and say:
1. That I am the very person executing this affidavit;
2. That I am the owner of an ______________________________;
3. (Enter Facts);
4. That the aforementioned _______________________ is now considered
lost and beyond recovery;
5. That I am executing this instrument to attest to the truthfulness of the
foregoing statements and for whatever purpose it may serve.
IN WITNESS WHEREOF, I have hereunto set my hand this ___ day of
___________, 2015 at ______________________________.

Affiant
SUBSCRIBED AND SWORN to before me this ____ day of _______, 2015 at
____________________________.

Doc No. ____

Page No. ____
Book No. ____
Series of 2015.