REPUBLIC OF THE PHILIPPINES )

PROVINCE OF CAVITE ) S.S.

AFFIDAVIT OF LOSS
I, JULIANA S. CASABUENA, of legal age, Filipino, with address at
Palumlum, Alfonso Cavite after having been sworn to in accordance with law,
hereby depose and state, that:

1. I was in possession of St. Peter ID and Policy/Contract issued by

St. Peter Life Plan with LPA # R12002327R;

2. Sometime last October 2019, I rode a van on my way home, and

when I reached the premises of my home, I found out that the
abovementioned ID card and Policy/Contract were missing and
nowhere to be found;

3. I surmised that said St. Peter ID and Policy/Contract have benn

accidentally dropped while I was on the van;

4. Despite diligent search and efforts to recover the said St. Peter ID
and Policy/Contract the same can no longer be located;

5. I am executing this affidavit not for any unlawful purpose but for
any valid and legal purpose only.

IN TRUTH WHEREOF, I have hereunto affixed my signature this 14 th day of

July 2020 at Alfonso, Cavite.

JULIANA S. CASABUENA
Affiant

SUBSCRIBED AND SWORN to before me this 14 th day of July 2020 at

Alfonso, Cavite. Affiant personally appeared to this office.
WITNESS MY HAND AND SEAL.

Doc. No. 262;.

Page No. 54;
Book No. LXXXII;
Series of 2020.