Republic of the Philippines )

City of ________ ) ss.

x----------------------------------x

AFFIDAVIT OF LOSS

I, _______________, of legal age, single, Filipino and a resident of

_____________________________________, after being sworn to in accordance with
law, do hereby depose and state that:

1. I am the owner and possesor of a wallet containing the following items:

a. xxxxxxxxxxxxxxxxxx
b. xxxxxxxxxxxxxx
c. xxxxxxxxxxxxxxxxxxxxxxx
a. xxxxxxxxxxxxxxxxxxxx

2. On ______ at about _______ in the afternoon, while I was in my house, I was

shocked to discover that my wallet containing the abovementioned items was
not anymore tucked in my back pocket pants. I started searching for my
wallet but to my dismay I failed to locate it;

3. I exerted diligent efforts to locate my wallet but to no avail;

4. Thus, due to the lapse of time I am considering my wallet as lost and beyond
recovery for all legal purposes;

5. That I am executing this affidavit in good faith to attest the truth of the
foregoing and to apprise the proper authorities concerned for the
issuance of a new one and for other purposes.

IN TESTIMONY WHEREOF, I have hereunto affixed my signature this ___ of ___,

_____ at Davao City, Philippines.

______________
Affiant

SUBSCRIBED AND SWORN to before me this ___________ at ____________.

Affiant is personally known to me to be the same person who executed this Affidavit of
Loss as competent proof of his identity.

Doc. No.___;
Page No. ___;
Book No. __;
Series of 2011.