REPUBLIC OF THE PHILIPPINES )

) S.S.

AFFIDAVIT OF LOSS

I, LUCHE SIMENE BARBAS, Filipino, of legal age, and a resident of

______________, after having been duly sworn in accordance with law, hereby
depose and say:

1. That I am the beneficiary of a St. Peter Life Agreement of the

deceased Lowella Barbas Chan;

2. That sometime in ________, I misplaced the said St. Peter Life

Agreement;

3. That despite diligent search and efforts to locate the said St. Peter Life
Agreement, such has not been found and it is my belief that it is now
lost beyond recovery;

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

facts and for whatever legal purpose this may serve.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___

day of ___________ at __________, Philippines.

LUCHE SIMENE BARBAS

Affiant

SUBSCRIBED AND SWORN TO BEFORE ME, a notary public in and for

_________ this ___ day of ___________ at __________, Philippines. Affiant
exhibited to me her _____________ ID bearing the numbers ____________
valid until _____________ as competent evidence of her identity.

Doc. No. ____;

Page No. ____;
Book No. ____;
Series of 20__.