REPUBLIC OF THE PHILIPPINES )

PROVINCE OF LAGUNA ) S. S.
MUNICIPALIT OF PILA )

AFFIDAVIT OF LOSS

I, JONATHAN A. REMOBLAS, of legal age, Filipino Citizen, with postal

address at Calumpang Liliw, Laguna, after having been duly sworn to in
accordance with law, depose and voluntarily state:

1. That I am a holder of Pantawid Pasada Program Card with account no.

___________________.

2. That the said Pantawid Pasada Card was misplaced and/or lost and could
not be found despite diligent effort locate the same;

3. That I exerted effort to look for the said Pantawid Pasada Card but to no
avail;

4. That I am executing this affidavit to attest to the truth of the above facts;

AFFIANT SAYETH NONE.

IN WITNESS WHEREOF, I have hereunto signed my name this 22 nd day of

August 2019 at Pila, Laguna.

JONATHAN A. REMOBLAS
Affiant

SUBSCRIBED AND SWORN TO before me this 22nd, day of August 2019

at Pila, Laguna with Certificate of Identity: Driver’s License with License No.
D12-94-028663.

Doc. No.: 936 ATTY. LOPE R. VELASCO

Page No.: 220 NOTARY PUBLIC
Book No.: 416 UNTIL DECEMBER 31, 2019
Series No.: 2019 PTR NO. 48121190/11-2019
IBP NP. 660381/ROLL NO. 28757
MCLE COMPLIANCE NP. V-000284