AFFIDAVIT OF LOSS REPUBLIC OF THE PHILIPPINES CITY OF MAKATI I, <
>, of legal age, <>, <>, a#% re"i%i#g a <>, afer &ei#g %!l$ "'or# i# a((or%a#(e 'i) )e la', %e*o"e a#% "a$+ - T)a I a. (!rre#l$ (!rre#l$ a# o'#er/ o'#er/ e#rolle%/&ear e#rolle%/&earer er of a# i#"!ra#(e i#"!ra#(e *oli($ *oli($ %e"(ri&e% %e"(ri&e% a" follo'"+ a&(%-
POLI POLIC CY NAME NAME + SUBS SUBSCR CRIB IBER ER NAME NAME + ISSU ISSUIN IN0 0 COM COMP PANY ANY + POLICY POLICY CO1ER CO1ERA0E A0E 2 SUB3E SUB3ECT CT +
4- T)a o# <<5ae of of o((!rre#(e>> o((!rre#(e>> )e a&o6e a&o6e "ai% %o(!.e#/*oli($ %o(!.e#/*oli($ 'a" 'a" <> a#% i" #o' (o#"i%ere% lo"7- T)a afer afer e8er(i"i#g e8er(i"i#g (o!#le"" .ea"!re" .ea"!re" a#% e9or e9or o re(o6er re(o6er i, )e )e "ai% %o(!.e# re.ai#" lo" a#% i" #o' &e$o#% re(o6er$:- T)a I a. e8e(!i#g e8e(!i#g )i" )i" a;%a6i for for )e *!r*o"e *!r*o"e of <>-
IN ITNESS HEREOF, I )a6e )ere!#o "e .$ )a#% )i" <<5ae>> <<5ae>> %a$ of <>, 4==, i# )e (i$ of Ma?ai, P)ili**i#e"-
_________________________ << FULL NAME >> AFFIANT
ACKNOWLEDGMENT Re*!&li( of )e P)ili**i#e"@ @ S-SBEFORE ME, a Noar$ P!&li( i# a#% for Ma?ai Ci$, )i" %a$ of , 4==, *er"o#all$ a**eare%+ Na.e CTC/TIN NoI""!e% o#/a ?#o'# o .e o &e )e "a.e *er"o# ')o e8e(!e% )e foregoi#g a;%a6i a#% a(?#o'le%ge% o .e )a )e "a.e i" )i" r!e a#% 6ol!#ar$ a( a#% %ee%IN ITNESS HEREOF, I )a6e "e .$ )a#% a#% "eal o# )e %a$, $ear a#% *la(e r" 'rie#Noar$ P!&li( 5o(- NoPage NoBoo? NoSerie" of
