REPUBLIC OF THE PHILIPPINES)

PROVINCE OF LAGUNA )S.S.

MUNICIPALITY OF SINILOAN )

AFFIDAVIT OF LOSS

I, ___, ___ years old, Filipino, married and a resident of ___, after
being duly sworn to in accordance with law, hereby depose and state:

1. That I am an owner of a black shoulder bag;

2. That sometime on September 24, 2018, I left the said bag in my

tricycle for a while and when I came back I found out the same was
already gone together with the following things belonging to me:

a. ATM pension;
b. Driver’s License;
c. T.I.N Identification;
d. Social Security System I.D.;
e. Voter’s Identification;
f. Certificate of Registration and Official Receipt of my
Tricycle for 2018;
g. Municipal Keys;
h. Rural Bank Book;
i. PhilHealth Identification;
j. Seiko 5 Watch;
k. Samsung Galaxy Grandprime Cellular phone;
l. Cherry Mobile Cellular phone;

3. That sometime today, September 25, 2018, I reported the

incident to the Police Station of ___, but despite diligent search and
effort to locate said bag, the same could not be found such that I
now believe it is now lost beyond recovery together with its
contents;

4. That I shall assume responsibility or liability if in any event I will

use this document for whatever illicit transactions;

5. That I am executing this affidavit to attest to the truth of the

foregoing facts and for whatever legal purpose it may serve;

IN WITNESS WHEREOF, I have hereunto set my hand this 25th day

of September 2018 at PAO Siniloan, Laguna.

______________________
Affiant

SUBSCRIBED AND SWORN to before me, this ____, by the Affiant at

the ____ whom I have identified through competent evidence of identity and
who exhibited his _____.

NOTARY