REPUBLIC OF THE PHILIPPINES )

BALAGTAS, BULACAN )
x-------------------------------------------x

AFFIDAVIT OF LOSS

I, NOEMI CONCEPCION SEBASTIAN, of legal age, Filipino citizen, single, and

presently residing at No. 309 Masuso, Pandi, Bulacan, after having been sworn in accordance
with law, do hereby depose and say that:

1. I am a holder of a Identification Card issued by the Professional

Regulations Commission (PRC) with registration No. 0851636, and
ATM card with account No. 1305-0327-15 issued by LANDBANK OF
THE PHILIPPINES (LBP)- Balagtas Branch, which I kept inside my
wallet;

2. However, the above-mentioned ID’s was among those items and

personal effect when there was a forced entry and someone broke into
my house last 25 June 2011 at around 1:00 o’clock in the morning.

3. Immediately, I reported the matter to the police, as evidenced of my

police report issued by the Philippine National Police-Pandi Police
Station, copy of which is hereto attached as Annex “A”.

4. I am executed this Affidavit to attest to the truth of the foregoing and for
whatever purposes this may legally serve especially to seek replacement
of the above-mentioned ID’s.

FURTHER AFFIANT SAYETH NAUGHT.

IN WITNESS WHEREOF, I have hereunto affixed my signature this 27 th day of June

2011 hereat Balagtas, Bulacan.

NOEMI CONCEPCION SEBASTIAN

Affiant

SUBSCRIBED AND SWORN TO before me this 27th day of June 2011 hereat Balagtas,
Bulacan.

Doc. No.: 477;

Page No.: 97;
Book No.: 33;
Series of 2011.