Republic of the Philippines )

Camiling, Tarlac
) S.S.

AFFIDAVIT OF LOSS
I, RUBY VELASCO y SIMON, of legal age, married, Filipino citizen
and a resident of Barangay Tuec, Camiling, Tarlac, Philippines, after having
been duly sworn to in accordance with law, do hereby depose and state
THAT:
1. Every time I buy groceries at the Sun Plaza Savewise,
Camiling,Tarlac, a corresponding raffle coupons was issued to me
and in time, I was able to accumulate several of them which I kept
in my shoulder bag for safekeeping;
2. On December 11, 2016, I rode on a bus from Camiling, Tarlac to
Manila. Upon reaching my destination, I alighted from the bus and
while I was walking, someone suddenly grabbed and took away my
shoulder bag;
3. With the help of some bystanders around the area, we tried to
catch the snatcher but he was able to run away. I was shocked by
the incident. I did not report the incident to the nearest police
station because I was not familiar in that place;
4. All the diligent efforts exerted to locate my shoulder bag containing
the above-said raffle coupons including the raffle coupon with
number 11203 and other personal belongings proved futile; hence,
I now consider them as lost and beyond recovery
5. I am executing this affidavit to attest to the truth of the foregoing
statements and for all legal intents and purposes this may serve.
IN WITNESS WHEREOF, I have hereunto affixed my signature this
12 day of December 2016 at Camiling, Tarlac, Philippines.
th

RUBY S. VELASCO
Affiant
SUBSCRIBED AND SWORN to before me on the date and place as
above-stated. Affiant exhibited before me her Voter Certification with VIN:
6903-0059B-C0677RSV20000-7 issued by the COMELEC, Camiling, Tarlac.

Doc. No.________;

Page No.________;
Book No.________;
Series of 2016.