Republic of the Philippines)

Province of Negros Oriental)s.s.

Municipality of Sibulan….)

AFFIDAVIT OF LOSS

THAT I, ANSELMO TRESFUENTES BARTOCES JR., of legal age, Filipino,

married, and a resident of San Antonio, Negros Oriental, under oath, do hereby depose and
manifest:

That I am working in Ninja Van as a delivery man. Sometime on February 10, 2019, I
was delivering items to our customers driving our RUSI Chariot I placed my wallet in my
back pocket;

That upon arriving in our office, I noticed that the said wallet was not anymore in my
pocket. Perhaps, the said wallet fell while I was driving the said RUSI Chariot delivering the
items to our customers;

That what were inside my wallet were the following important document and IDs, to
wit:
1. Professional Driver’s License issued by the LTO Dumaguete City
2. SSS ID
3. Philhealth ID
4. BDO ATM Card
5. BIR ID
6 Certificate of Registration of my Motorcycle with Plate Number 090103

That I have reported the said incident to the Police Station of Sibulan, Negros Oriental
and I have exerted all efforts to locate the aforementioned items, but despite diligent efforts
exerted to locate them, the same can no longer be found;

That this affidavit is executed freely and voluntarily just to attest the truthfulness and
veracity of the statements alleged herein.

IN WITNESS WHEREOF, I have hereunto affixed my signature this 11 th day of

February, 2019, at Sibulan, Negros Oriental.

ANSELMO TRESFUENTES BARTOCES JR.,

(Affiant)

SUBSCRIBED AND SWORN to before me, a Notary Public, on this 11th day of
February, 2019, for the Municipality of Sibulan and the Province of Negros Oriental,
Philippines, the above-named affiant, who is personally known to me, and WHO SIGNED
IN MY PRESENCE the foregoing document (Affidavit of Loss), and who avows under
PENALTY OF LAW to the whole truth of the contents of the same.

Doc No. _________;

Page No. ________;
Book No. ________;
Series of 2019