REPUBLIC OF THE PHILIPPINES)

) S.S.
___________________________)
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AFFIDAVIT OF LOSS

I, HAZEL D. GRANADA, of legal age, Filipino, with

residence at 1 Cor. Gonzaga-Jalandoni St., Brgy. II
Victorias City, Negros Occidental, after first being duly
sworn according to law, depose and say:

1. That RUSSELL D. GRANADA is a bona fide plan

holder of ST. PETER LIFE PLAN, INC. with LPA No.
N11003637A under _______________________ located at
________________________________;

2. That recently, when I looked for the Certificate

of Full Payment with COFP # VWT115_010139, I
realized it was lost, and despite of exhaustive
efforts to locate and find it, the same however
proved futile;

3. That all circumstances above-stated are true to

my own knowledge;

4. That I am executing this affidavit in order to

state the fact of the loss of the said Certificate
of Full Payment.

IN WITNESS WHEREOF, I have hereunto affixed my

signature this __________at _____________________.

HAZEL D. GRANADA
Affiant

SUBSCRIBED AND SWORN to before me this

__________________ at __________________, affiant exhibited
to me her ________________________.

NOTARY PUBLIC

DOC. NO. ________

PAGE NO. _______
BOOK NO. _______
SERIES OF 2021