Republic of the Philippines)

Province of Agusan del Sur) S. S.

AFFIDAVIT OF LOSS

I, MARCELYN P. MONATO, Filipino, of legal age and a resident of Purok 13,

Poblacion, Propseridad, Agusan del Sur, Philippines, after having been duly sworn to
in accordance with law, do hereby depose and say:

1. That I am a bona fide plan holder of St. Peter Life Plan, San Francisco,
Agusan del Sur;

2. That relative thereto, a LPA/Contract bearing LPA No. N15073430D was

issued in my favour;

3. That undesirably however, the aforesaid Original LPA/Contract was lost

sometime in the month of February, 2020;

4. That I have exerted my best efforts to locate and recover the aforesaid Original
LPA/Contract, but despite diligent search made, my efforts proved futile. I
now consider the same irretrievably lost;

5. That I am executing this affidavit to attest to the veracity of the foregoing

particularly to prove the loss of the above-mentioned Original LPA/Contract.

IN WITNESS WHEREOF, I have hereunto set/affixed my signature this 4 th day

of June 2020 at Patin-ay, Prosperidad, Agusan del Sur, Philippines.

MARCELYN P. MONATO
Affiant

SUBSCRIBED AND SWORN TO before me this 4th day of June 2020 at Patin-
ay, Prosperidad, Agusan del Sur, Philippines

June 4, 2020

The Manager
St. Peter Life Plan inc.
San Francisco, Agusan del Sur
Maam,

I would like to request for reinstatement of my St. Peter LPA with Contract
bearing LPA No. N15073430D, which has been automatically terminated and cancelled
as provided in the pertinent provisions of the Contract, due to my failure to pay
installments within sixty (60) days from due date.

Before it was terminated, I made 35 instalments for my policy and now has a
remaining balance of P23,750 to be paid. Should this request be granted, I will pay the
entire balance.

I’m hoping for your consideration and approval of this request. Thank you.

MARCELYN P. MONATO III

Plan Holder