REPUBLIC OF THE PHILIPPINES

CITY OF BACOOR

AFFIDAVIT OF LOSS

KNOW ALL MEN BY THESE PRESENTS:

I, NORMAN JOY D. STA ANA, of legal age, Filipino citizen, widowed,

and a resident of Blk 1, Lot 14 RCD Villas De Bacoor Dulong Bayan Bcoor
Cavite, after having been sworn in accordance with law, hereby deposes and state
the following:

1. That on September 21, 2020 around 5:00 pm at Pasay Rotonda while I am

waiting for a bus to ride, my wallet was pick-pocketed without my
knowledge;

2. That my wallet contained my Driver’s License, SSS ID, Philhealth ID,

Brangay ID, Police Clearance ID, Voter’s ID, BDO ATM CARD,
MAYBANK ATM CARD, INC. ID, HMO Health Care Card and FEAC ID;

3. That despite diligent search and efforts to locate my wallet I could not find
them such that I now believe that they are now lost beyond recovery;

4. As such, I am executing this Affidavit of Loss to attest to the truth of the

foregoing facts and to use the same for whatever legal purpose it may serve.
IN WITNESS WHEREOF, we hereunto set our hands this ________
September 2020 in Bacoor City Philippines.

NORMAN JOY D. STA ANA

Affiant

BEFORE ME, a Notary Public for and in the above jurisdiction, this 22 nd
day of September, 2020 at __________, personally appeared, showing his
________________ issued by the ________ on ______________, known to me
and to me known to be the same person who executed and signed the foregoing
instrument and who acknowledged to me that the same is her free voluntary act
and deed.

WITNESS MY HAND AND SEAL on the place and date first above
written.

Doc. No. ____; Notary Public

Page No. ____;
Book No. ____;
Series of 2020.