REPUBLIC OF THE PHILIPPINES)

PROVINCE OF BULACAN ) S.S.

CITY OF MEYCAUYAN )

AFFIDAVIT OF LOSS

I, ________________________, Filipino, of legal age, and a resident of No.88,

Libtong Meycauayan Bulacan, after being duly sworn to in accordance with law, hereby depose
and state:

1. That I am the holder of the following DOCUMENTS;

a. ________________
b. ______________________________
c. _____________________________

2. That on ______________________, I misplaced the above inumerated

documents, and despite diligent efforts exerted to locate the SAME, I could not remember
exactly where I placed/left thus, considered it lost for all legal purposes;

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

foregoing and to support my application for the issuance ANG/OR replacement OF the above
enumerated documents.

IN WITNESS WHEREOF, I have hereunto set my hand this

_______________________ at _____________________, Philippines.

______________________
Affiant

SUBSCRIBED AND SWORN to before me in the City of Meycauayan, Bulacan, this

_______________, 2017 by __________________ with ____________________ ID No.
_______________, who has satisfactorily proven to me her identity through her competent
evidence of identity, and that she is the same person who personally signed before me the
foregoing affidavit and acknowledged that she executed the same.

Doc No. : _____;

Page No. : ___;
Book No. : ___;
Series of 2017.