Republic of the Philippines

Region VI-Western Visayas

Province of Aklan
Municipality of Ibajay

AFFIDAVIT OF LOSS
Know All Men by These Presents:
I, ANTONIO G. MAGPUSAO, 60 yrs. of age, Filipino and a resident of
Poblacion, Ibajay, Aklan, do hereby depose and state:
1. That I am at present employed as Principal II of Ibajay Central School, Ibajay
West District;
2. That I have been a continuing member of the Manila Teachers SLA-Savings
and Mutual Aid since the date of application up to February, 2009;
3. That stoppage of deduction in my salary has been effected effective March,
2009;
4. That I would like to claim the remaining proceeds of my savings with the
Manila Teachers, Inc.;
5. That I cannot present my bankbook because it was lost and might have been
washed away together with my other personal documents when Typhoon Frank hit our
place sometime last June 21, 2008;
Done on this 24th day of April, 2009 at Ibajay, Aklan, Philippines.

ANTONIO G. MAGPUSAO
Claimant
SUBSCRIBED and sworn to before me this
day of April, 2009 at
, affiant exhibited to me his Community Tax
Certificate No. 16951785 issued at Ibajay, Aklan on January 9, 2009.
Doc. No.
Page No.
Book No.
Series of 2009