AFFIDAVIT OF LOSS

I, [SPECIFY NAME], domiciled and residing at [YOUR COMPLETE ADDRESS], do hereby solemnly declare that:

1) I am the [TITLE] of [COMPANY] and as such have knowledge of the facts herein declared.

2) [COMPANY], a wholly-owned subsidiary of [SPECIFY COMPANY], executed a Trust Deed of Hypothec bearing formal date of [DATE] in favor of [SPECIFY]. (“SPECIFY”), which deed was registered at the Registry Office in and for the Registration Division of [SPECIFY PLACE] on [DATE] under the number [NUMBER] (the “Trust Deed”).

3) [SPECIFY COMPANY] issued a [%] mortgage bond certificate number [NUMBER] in the principal amount of [AMOUNT] in legal currency of [COUNTRY] (the “Bond”) pursuant to the Trust Deed, which Debenture [SPECIFY COMPANY] then pledged in favor of [SPECIFY COMPANY] on [DATE], and which pledge was registered by [SPECIFY] in the register kept for such purpose, as per the trustee’s attestation on the reverse of the Bond (a photocopy of which is attached hereto).

4) [SPECIFY COMPANY] assigned the indebtedness of [SPECIFY COMPANY] which the Trust Deed was executed and the Bond issued and pledged to secure (the “Indebtedness”) to [SPECIFY COMPANY] (“COMPANY”) pursuant to an Agreement of Absolute Assignment dated as of [DATE] by and between [SPECIFY COMPANY] and [SPECIFY COMPANY] (the “Assignment”) (a copy of which is attached hereto).

5) [SPECIFY COMPANY] has received the Bond, but has lost same, and although [SPECIFY COMPANY] has made a due and diligent search therefore, [SPECIFY COMPANY] has been unable to find the Bond.

6) Said Bond has not been endorsed by [SPECIFY COMPANY], save and except for the endorsement to [SPECIFY] as of [DATE] (the “Endorsement”) pursuant to the Assignment (a copy of the Endorsement is attached hereto). Save and except for the Assignment and Endorsement, [SPECIFY COMPANY] has not executed or signed any other instrument of transfer in connection with the Bond or the Indebtedness, nor has [SPECIFY COMPANY] otherwise sold, assigned, transferred, pledged, hypothecated or in any way encumbered or disposed of the Bond or the Indebtedness or any rights therein.

7) [SPECIFY COMPANY] hereby accordingly requests [SPECIFY] to issue a new mortgage bond certificate to [SPECIFY COMPANY] in replacement of the Bond lost and assigned to [SPECIFY COMPANY].

8) I have executed this Affidavit of Loss in support of [SPECIFY COMPANY]’s request that a new mortgage bond certificate be issued to [SPECIFY COMPANY] by [SPECIFY].

DATED this [DAY] day of [MONTH, YEAR].

AND I HAVE SIGNED

SOLEMNLY DECLARED before me

at [SPECIFY place] this [DAY] day

of [MONTH, YEAR]

Commissioner for Oaths, Notary Public,

Solicitor authorized to administer oaths

or equivalent