REPUBLIC OF THE PHILIPPINES )

CITY OF ILOILO )
X.X

AFFIDAVIT OF LOSS

I, Alice M. Garin, Filipino, of legal age, married and a resident of Fatima Subdivision, Sta, Cruz,
Arevalo, Iloilo City, Philippines, after having duly sworn to in accordance with law, hereby
depose and say that :

1. I am an insurance agent of Prulife UK, Insurance Corp (Prulife UK) and has been issued
Provisional Receipt Nos. 3045001 3045010 ;
2. That in the course of my being an agent of Prulife UK, I issue these receipts to my clients
once they pay their premiums payable to Prulife UK ;
3. That on May 29, 2017, I issued Provisional Receipt No. 3045003 to Dr. Lister P. Leonida
in the total amount of P 10,500.00 and released the original PR No. 3045003 to him on
that same day ;
4. That after a while it was discovered that there was an error in the same said PR no.
3045003 causing its cancellation and in lieu thereof a new PR No. 3045004 and 3045005
were issued ;
5. That I retrieved the said PR No. 3045003 from the client, however, the same said
original PR No. 3045003 was misplaced and I could not exactly remember where I placed
or left it and thus it is considered lost for all legal purposes ;
6. I am executing this affidavit to attest to the foregoing facts.

ALICE M. GARIN
Affiant
SUBSCRIBED AND SWORN to before me this _______________in the City of Iloilo,
Philippines, affiant exhibited to me her Drivers License No.___________expiring
on_________at Iloilo City.

Doc. No. ____;

Page No.____;
Book No.____;
Series of 2017