Affidavit of Loss Official Receipt OR for Bail Bond)

REPUBLIC OF THE PHILIPPINES)

Province of ____________________) S.S.
City/Municipality of _____________)
x-----------------------x

AFFIDAVIT OF LOSS

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

_____________, Philippines, after being duly sworn in accordance with law,
depose and state:

That I am defendant in Criminal Case No. _____________ before the

_____________ Trial Court, Branch ______, _____________ City,
which is for _____________;

That on _____________ and to secure my provisional liberty in the

said criminal case, I posted a Cash Bail Bond in the amount of
_____________ (P_____________) and was issued Official
Receipt No. _____________;

As the aforementioned criminal case against me was already

dismissed, I looked for the original copy of the said Official Receipt
No. _____________ to get back my cash bail bond;

However, despite diligent search and efforts to locate the said original
copy of the said Official Receipt No. _____________, the same
could not be found and must have been misplaced and
 irretrievably lost, such that I now believe that it is now lost beyond
recovery;

As such, I am executing this Affidavit of Loss to attest to the truth of

the foregoing and in support for my request for the release of my
P_____________ cash bail bond and for whatever legal purposes
that this may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this _____________ at

_____________, Philippines.

AFFIANT

(JURAT)