Republic of the Philippines)

Province of Southern Leyte) s.s.

Municipality of S OGOD )
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AFFIDAVIT OF LOSS

I, RIZA M. ANIMOS, of legal age, married, Filipino and a resident of Buenavista,

Bontoc, Southern Leyte, after having been duly sworn to an oath in accordance with law,
hereby depose and say:

1. That I am a holder of Unified Multi-Purpose I.D. issued to me by GSIS Office,

Maasin City, Southern Leyte;

2. That as such, I was issued a Unified Multi-Purpose I.D. by the aforementioned

Office which I placed inside my wallet;

3. That sometimes on May 19, 2012, the aforementioned Unified Multi-Purpose I.D. got
lost and nowhere to be found;

4. That I exerted an exhaustive efforts to locate the same but our search proved futile as
we could not locate the same up to the present;

5. That I executed this affidavit in order to attest to the truth and veracity of the
foregoing so that we will be issued another one and for whatever legal intents and
purposes this may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this 31st day of May, 2012 in the
Municipality of Sogod, Southern Leyte, Philippines.

RIZA M. ANIMOS
Affiant

SUBSCRIBED AND SWORN to before me this 31st day of May, 2012 at Sogod,
Southern Leyte, Philippines.