AFFIDAVIT OF LOSS

I, Andres M. Cornejo after first being sworn to in accordance with, hereby depose and say:

1. That__________________________ sometime in________________, ____________________________I subscribed to and paid for __________(___) common shares in _______________________(the “Corporation”)in the amount of PESOS ______________________(PhP____________);

2. That in consideration of said subscription payment, the Corporation issued Stock Certificate No/s. __________________in my name ;

3. That the aforesaid Stock Certificate No/s. _____________________ have been lost or misplaced and could not be found notwithstanding diligent efforts to find the same;

5. That I have not sold, assigned, transferred, disposed of, or encumbered in any manner whatsoever the common shares covered by said stock certificate/s and that I am still the owner of the common shares in my own right;

6. That I execute this affidavit to attest to the loss of the aforesaid Stock

Certificate No/s._________________________ of the Corporation and to request the issuance of a new stock certificate in my name as evidence of ownership of said shares;

7. That I hereby tender a good and sufficient bond of indemnity or other security acceptable to the Corporation, and do hereby hold and bind myself in my personal capacity to pay and indemnify the Corporation, its successors and assigns, against all claims, demands and actions arising from or on account of said original stock certificate/s, and against all damages, costs, and expenses by reason thereof, and shall deliver or cause to be delivered said original certificate to the Corporation for cancellation if the same shall be found. FURTHER, I SAY NONE.

____________________________ Affiant

Republic of the Philippines )______________________ ) SS.

SUBSCRIBED AND SWORN TO before me this ____ day of _____________ 2015, affiant exhibited his _____________________________________________________________.

Doc. No. _____Page No. _____Book No. _____Series of 2015.