REPUBLIC OF THE PHILIPPINES  )

CITY     OF   SURIGAO   ) S. S.
X----------------------------------------------X
 
AFFIDAVIT OF LOSS 

I, LORGESSIE T. CABUG-OS, Filipino, of legal age, married and a resident of

Mabini, Placer, Surigao del Norte, Philippines, after having duly sworn to in
accordance with law, hereby depose and say that:

1. I am the wife of ALFREDO S. CABUG-OS, JR.

2. We were in possession of the BAPTISMAL CERTIFICATE of my husband

ALFREDO S. CABUG-OS, JR. in our house, with our other important
documents.

3. I, together with my husband, and our family, exerted diligent and

earnest efforts to locate the BAPTISMAL CERTIFICATE of my husband
ALFREDO S. CABUG-OS, JR. but the same remains futile.

4. As such, I am executing this affidavit to attest to the foregoing facts, to

establish its loss and for whatever legal purpose that this affidavit may
serve;
 
       IN WITNESS WHEREOF, I have hereunto set my hand this 22 nd day of May
2015 in the City of Surigao, Philippines.
                                
         LORGESSIE T. CABUG-OS
Affiant

SUBSCRIBED AND SWORN to before me this 22nd day of May 2015 in the
City of Surigao, Philippines. Affiant exhibited to me her LGU I.D. with I.D. no. 55,
issued by Municipality of Placer, Agriculture Office.