Republic of the Philippines)

Malaybalay City, Bukidnon) S.S

AFFIDAVIT OF LOSS

I, VIOLETA B. CRUZ, of legal age, married, Filipino citizen and a

resident of Brgy. 1, Malaybalay City, Bukidnon, after having been duly
sworn to an oath in accordance with law, hereby depose and say:

1. That I am obtained a funeral plan from St. Peter Life Plan, Inc.
Malaybalay City Branch;

2. That I have been faithfully and religiously paid my monthly dues

for the said plan;

3. That sometime on the year 2019, I was able to fully pay the said
plan and I was a Certificate of Full Payment by St. Peter Life Plan,
Inc.;

4. That, unfortunately, the said Certificate of Full Payment was lost in

my possession;

5. That all efforts were exerted to look for the said Certificate of Full
Payment, but it proved futile and it is beyond recovery and is
deemed lost for all intent and purpose;

5. That I am attesting to the truth and veracity of the foregoing facts;

6. That I am voluntarily executing this affidavit for whatever legal

purpose/s it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this 14th day of

January, 2020 at Malaybalay City, Bukidnon.

VIOLETA B. CRUZ
Affiant

SUBSCRIBED AND SWORN to before me this 14th day of January, 2020

at Malaybalay City, Bukidnon, Philippines. Affiant is personally known to
me to be the person who executed this Affidavit. I HEREBY CERTIFY that I
have personally examined the affiant and I am satisfied that she voluntarily
executed and understood this affidavit.

Doc. No. 204

Page No. 42
Book No. IV
Series of 2020