AFFIDAVIT OF LOSS

I, _______________________________________, of legal age, and having been duly sworn

in accordance with law, hereby state the following:

1. I am the Planholder of record of a pre-need plan (the “Plan”), entered into by

contract with PhilPlans First Inc. (PhilPlans), with Plan No.
____________________________.

2. Said plan has been fully paid on [date] and PhilPlans provided me with a
Certificate of Full Payment (the “Certificate”) with reference no. [number].

3. When asked to present my copy of the Certificate in order to avail of certain

benefits from PhilPlans, I realized that I had inadvertently misplaced my copy;

4. Despite a diligent and exhaustive search for my copy of the Certificate, I was
unable to locate it, and must assume that it is now lost and irretrievable;

5. I am executing this Affidavit to attest to the truth of the foregoing, to support my

application for a new copy of the Plan to be issued, and for whatever other official
and lawful purposes it may serve.

FURTHER AFFIANT SAYETH NAUGHT.

IN WITNESS WHEREOF, I have hereunto signed these presents on this _____ day of
______________________ 2011 in _________________________________.

__________________________________
Affiant

REPUBLIC OF THE PHILIPPINES )

_________________ CITY ) S.S.

SUBSCRIBED AND SWORN to before me this _____ day of

_________________________________ in ________________________, affiant exhibiting to
me the following proof of identity:

Doc. No. ____

Page No. ____
Book No. ____
Series of _______.

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8 Floor, PhilPlans Corporate Center, Kalayaan Avenue, Triangle Drive, Fort Bonifacio, Taguig City