REPUBLIC OF THE PHILIPPINES )

CITY OF ___________________ ) S.S

AFFIDAVIT OF LOSS
I, _______________________, of legal age, single and residing
at_______________________________________, after having been duly sworn
to according to law hereby depose and state:
1. That we lost ____________________;
2. That on _________________________, the said ______________
must have slipped from documents because after I reached my office, I
hurriedly tried to it but I was a little bit shocked as it was not there
anymore;
3. That after diligent search, the said ____________ was nowhere
to be found anymore;
4. That I am executing this affidavit in order to attest to the
truth of the foregoing circumstances and for the purpose of reporting
the loss to the Globe business center.
IN WITNESS WHEREOF, I have hereunto set my hand this ___day
of ______________________, 2011 at _______________________.

______________________
Affiant
SUBSCRIBED AND SWORN to before me this ____ day of _______________, at
Makati City, Philippines, Affiant exhibiting to me his/her Community Tax
Certificate No. ____________________ issued on ___________________ at
___________________
and
________________________
ID
issued
on
___________________ at ___________________ .

NOTARY PUBLIC
Doc. No. _____
Page No._____
Book No._____
Series of _____.