REPUBLIC OF THE PHILIPPINES)

PROVINCE OFBUKIDNON )ss

CITY OF VALENCIA )

AFFIDAVIT OF LOSS

I, _____________________________________ of legal age, single, Filipino

citizen, and a resident of ________________________________ after being

sworn in accordance with the law depose and say:

1.) I am a holder of a __________________ issued by

______________________________;

2.) The foregoing __________________________ with I.D No. 0748463

was lost on _____________________ because

______________________;

3.) That despite diligent efforts has been exerted in order to find and locate

the said _____________________; the same could no longer be found

and proved to be beyond recovery;

4.) That this affidavit was executed to attest the truth of the foregoing and

for purposes of the re-issuance of a new __________________ in my

favor and whatever legal purposes it may serve best.

IN WITNESS WHEREOF, I have here unto set my hand this 17

th day of January, 2013 in

the City of Valencia, Province of Bukidnon.

__________________________ Affiant

SUBSCRIBED AND SWORN to before me this 18

th day of January, 2013 at Valencia

City, Province of Bukidnon.

NOTARY PUBLIC

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