Affidavit of Loss Id

REPUBLIC OF THE PHILIPPINES) CITY OF _______ )S.S. X - - - - - - - - - - - - - - - - - - - - - - - -X

AFFIDAVIT OF LOSS

I,  _____________________ , Filipino, of legal age, single/a!!ie" an" a !esi"en# of   _______________  ______________________ ___________, ____, P$ilippines, af#e! $a%ing "&l' s(o!n #o in ao!"ane ao!"ane (i#$ la(, $e!e*' "epose an" sa' #$a#+ . I a a $ol"e! of a s#&"en# s#&"en# I"en#ifi I"en#ifia#ion a#ion Ca!" Ca!" iss&e" iss&e" *'  ______________  ____________________ _____________ _________ __ . I los# sai" sai" I"en#ifia#ion I"en#ifia#ion Ca!" Ca!" on _______ ______________ _____________ ______ an" #$a# I ee!#e" ee!#e" all effo!#s #o loa#e #$e sae *&# I o&l" no# !ee*e! ea#l' ($e!e I plae"/lef# i# an" i# is onsi"e!e" los# fo! all legal p&!poses0. Sai" I"en#ifia#io I"en#ifia#ion n Ca!" (as no# onfisa#e" onfisa#e" *' an' an' offie! offie! of #$e la( o! #$e #$e offie!s of 1nae of s$ool) *' !eason of an' %iola#ion of an' la(, o!"inane, p!esi"en#ial "e!ee o! !&les an" !eg&la#ion of sai" &ni%e!si#'- an" nei#$e! (as i# offe!e" as olla#e!al fo! an' loan2. I a ee&#ing ee&#ing #$is affi"a%i# affi"a%i# #o a##es# a##es# #o #$e #$e fo!egoing fo!egoing fa#sfa#sIN WITNESS WHEREOF , I $a%e $e!e&n#o se# ' $an" #$is ______________ in #$e Ci#' of _____________, P$ilippines.  ________________   3ffian# SUBSCRIBED SUBSCRIBED AND SWORN  #o *efo!e e #$is ____________ in #$e Ci#' of   __________,  __________, P$ilippines, P$ilippines, affian# affian# $a%ing e$i*i#e" e$i*i#e" #o e $is/$e! o&ni#' o&ni#' #a e!# e!#if ifi ia# a#e e (i#$ (i#$ no. no. ____ ______ ____ ____ ____ ____ ____ ____ __ iss& iss&e" e" on ____ ______ ____ ____ ____ ____ ____ ___ _ a#  ______________  ______________ .

4o. No. ________Page No. ________Boo5 No.________Se!ies of 6.