Republic of the Philippines)

City of Tagbilaran ) S.S.

AFFIDAVIT OF LOSS

I, MC KOLBE L. LAGERA, Filipino, of legal age, single, and with

residence at Pantudlan, Cabilao, Loon, Bohol, Philippines, after being duly sworn
to in accordance with law, hereby depose and state:

That I am a holder/owner/possessor of Seafarers Identification and

Record Book or commonly known as Seaman’s Book which was issued by the
Maritime Industry Authority (MARINA);

That on or about September 26, 2018, the Seafarers Identification and

Record Book or Seaman’s Book, was lost and its whereabouts cannot be
ascertained despite due and diligent search made and undertaken such that I
now believe that the same is lost beyond recovery;

That I now request the MARITIME INDUSTRY AUTHORITY to issue a

new Seafarers Identification and Record Book or Seaman’s Book in lieu of the
lost one and I bind myself to surrender the lost Seaman’s Book in the event that
the same is found and/or located;

That I covenant to indemnify Maritime Industry and Authority for any loss
and damage it may incur by reason of its issuance or replacement;

That I am executing this affidavit to attest to the veracity of the above-

stated facts, for the purpose of the issuance of a new Seafarers Identification and
Record Book or commonly known as Seaman’s Book or any other legal purpose
which this affidavit may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this 2 nd day of

October, 2018 at Tagbilaran City, Philippines.

MC KOLBE L. LAGERA
Affiant

SUBSCRIBED AND SWORN TO BEFORE ME this 2 nd day of October,

2018 affiant personally presented to me his community certificate no.
__________________, as competent and valid proof of his identity.

Doc No. _____;

Page No. _____;
Book No. _____;
Series of _____.