Republic of the Philippines )

City of _______ ) S.S

X ------------------------------ X

AFFIDAVIT OF LOSS

I, ____________, of legal age, single, and a resident of ____________,

after having duly sworn to an oath hereby declares:

That I was issued a CPA Professional License Card by the Professional

Regulation Commission (PRC);

That I usually placed the said PRC License Card inside my wallet;

That however, sometime in the first week of December, 2017, while I was
retrieving the said license card from my wallet purposely to photocopy it, I
discovered that it was no longer there;

That despite diligent efforts to locate my PRC License Card, the same could
not be found, thus I hereby declare that the said CPA License Card issued by PRC is
lost and beyond recovery;

That I am executing this affidavit to attest to the truth of the foregoing facts
and for whatever legal purposes and intents this may serve.

IN WITNESS WHEREOF, I have hereunto affixed my signature this

_____________, at ______________, Philippines.

Affiant

Signed in the presence of: ________________ _________________

SUBSCRIBED AND SWORN TO BEFORE me this ____________, at

_______________, Philippines, Affiant presented her SSS ID with No.
________________ as her competent evidence of identity.