AFFI DAVI T

REPUBLIC OF THE PHILIPPINES }

PROVINCE OF CAMARINES NORTE } S.S.
MUNICIPALITY OF DAET }

I, _____________________, of legal age, married and resident of P-4, San Jose,

Talisay, Camarines Norte, Philippines, after having been duly sworn to in accordance with
law , hereby deposes and says:

1. That I am a driver of Twin Hearts Bus Company and a member of Social Security
System;

2. That I applied for loan from the Social Security System with an amount of Three
Thousand Five Hundred Pesos (P3500.00) last July 2009;

3. That the said application was granted and the said office issued a check in my favor
addressed to the main office of the bus company where I work located in Anahaw,
Labo, Camarines Norte;

4. That unfortunately on August 2009, the main office of the said company was burnt
and was relocated to Central Plaza Complex, along San Vicente Road, Lag-on, Daet,
Camarines Norte;

5. That for this reason, I still haven’t received the check being issued to me by the Social
Security System up to this moment;

6. That I am executing to attest to the truth and veracity of the foregoing and for
whatever legal purposes it may serve me;

FUTHER AFFIANT SAY NAUGHT.

IN WITNESS WHEREOF, I have hereunto set my hand this __ day of ________

2009, in the Municipality of Daet, Province of Camarines Norte.

_________________________
Affiant

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2009 at Daet,
Camarines Norte.

ATTY. GODFREY A. PARALE

NOTARY PUBLIC
Doc. No._____ Until December 31, 2010
Page No.______ Roll No.53896:6/8/2007 Manila
Book No._____ IBP No. 734294: 1/6/09 Daet
Series of 2009 PTR No.:7201203 1/6/09 Daet
MCLE COM NO. III-0000768