Republic of the Philippines ___________________ City

] ] s.s. AFFIDAVIT OF LOSS

I, DALU DO ! I"AO #OTI , of legal age, Filipino, with residence and postal address at Shariff Mansion, Gunao St., 340 Quiapo, Manila, after having been dul sworn to in accordance with law, hereb deposes and sa s, that! ". I a# a securit guard assigned at Sogo $otel, %antranco &ranch, with wor' schedule fro# (!00 p.#. to (!00 a.#. ). *n Ap$il %&' %(() at around +!00 a.#. near ,oosevelt -venue and on # wa ho#e, I rode a passenger .eep going to Quiapo, Manila. 3. /hen I alighted at Quiapo, Manila, I discovered that # clutch bag was alread #issing which contains, a#ong others, # %lastic Securit 0icense together with other personal belongings. 4. I e1erted earnest effort to loo' for the said clutch bag but the sa#e proved futile. 2hus, the said %lastic Securit 0icense #a now be considered a lost ite#. 3. I e1ecute this affidavit to attest to the truth of the above facts.

I *IT +SS *,+R+OF, I hereunto affi1 # signature below this 4444 da of Ma )005 at 44444444444444, %hilippines. DALU DO ! I"AO #OTI Affi-nt SU"SCRI"+D A D S*OR to before #e this 4444 da of Ma )005, affiant e1hibited to #e his 6o##unit 2a1 6ertificate 7o. 44444444444444444 issued on 44444444444444444 at %ara8a9ue 6it , %hilippines.

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OTAR. PU"LIC