REPUBLIC OF THE PHILIPPINES )

City of Roxas ) S.S.

x-------------------------------------------x

AFFIDAVIT OF LOSS

I, LORENA E. CANOBIDA, Filipino, of legal age, married and a

resident of Brgy. Bito-on Ilaya, Cuartero, Capiz, after having been
duly sworn in accordance with law, hereby depose and state:

1. That I am a holder of a TIN, SSS, PAG-IBIG,

PHILHEALTH and POSTAL Identification Card;

2. That said cards were placed and kept inside our house;

3. That on January 1, 2020 at around 12:10 in the morning

while we were sleeping inside our house, we were
awakened by the smoke coming from our bedroom made
of light materials. The house was covered by smoke and
fire immediately had spread all over the house. The
house was totally burned;

4. That on said incident, my family’s safety including my

husband and two minor children was my top priority.
Everything was succumbed by fire including those
above-mentioned identification cards;

5. We were left by nothing except ourselves and

some personal important belongings;

6. That I am executing this affidavit to attest to the truth of

the foregoing facts and to request for a replacement of
said cards.

IN WITNESS WHEREOF, I have hereunto set my hand this 6 th

day of January, 2020 at the Roxas City, Philippines.

LORENA E. CANOBIDA
Affiant

SUBSCRIBED AND SWORN to before me this 6th day of

January, 2020 in the City of Roxas, Philippines. I further CERTIFY
that I have personally examined the affiant, and I am fully
satisfied that he voluntarily executed the foregoing Affidavit, and
he read and understood the contents thereof.