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Republic of the Philippines

Republic of the Philippines

)

Province of ______________

) S. S.

Municipality of ________________)

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

Affidavit of Loss

I, __________________________, of legal age, Filipino and a resident of _____________________________, after having been duly sworn to in accordance with law, hereby depose and say:

1. That I am the very person executing this affidavit;

2. That I am the owner of a ______________________________;3. That however on date-, (facts);4. That the aforementioned _______________________ is now considered lost and beyond recovery; 5. That I am executing this instrument to attest to the truthfulness of the foregoing statements and for whatever purpose it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this ___ day of ___________, ______ at ______________________________.

AffiantSUBSCRIBED AND SWORN to before me this ____ day of _______, _____ at ____________________________.

Doc No. ____Page No. ____

Book No. ____

Series of ______.


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