REPUBLIC OF THE PHILIPPINES)

PROVINCE OF TARLAC ) S.S.

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

AFFIDAVIT OF LOSS

I, ______________, of legal age, Filipino, married and a resident of Barangay

Nancamarinan, Paniqui, Tarlac, after having been duly sworn to in accordance with law, depose
and state:

1. That I am a holder of CERTIFICATE OF MEMBERSHIP, issued by Manila

Teacher’s Mutual Aid System, Inc., Ermita, Manila;

2. That my effort to locate the THE ORIGINAL COPY OF CERTIFICATE OF

MEMBERSHIP proved in vain and I have given it up as lost for all intent and purposes;

4. That diligent effort to locate the same proved futile;

5. That I am executing this affidavit to attest to the foregoing facts and for any legal
purpose it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this 3rd day of November 2017 in
Paniqui, Tarlac , Philippines.

Affiant

SUBCRIBED AND SWORN TO before me this 3rd day of November 2017 in Paniqui,
Taralc, Philippines, affiant exhibiting to me his valid proof of identification.

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 2017.