Republic of the Philippines)

La Trinidad, Benguet) s.s

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AFFIDAVIT OF LOSS

I, ADELE OLIVE MARCELO, of legal age, married, Filipino, and a resident of IC 47 Betag, La
Trinidad, Benguet after having been duly sworn to in accordance with law, do hereby depose and state
THAT:

1. I am a St. Peter Life Plan Member, with Policy LPA/LPC No. R14007203G. As such, I had
been paying my installment payments, the latest of which was on July 31, 2018, as evidenced
by Official Receipt No. 0373674;

2. The said St. Peter Life Plan Member Policy has been kept safely in my personal cabinet
inside our house since it was issued until it was lost or misplaced, as follows:

3. Sometime about the 2nd week of August 2018, when I tried to locate the said St. Peter Life
Plan Policy in my cabinet at Km. 6, La Trinidad, Benguet, I noticed that the same is missing.
I tried to locate in my folders, files and even in other places where I might have kept but I
cannot able to find the same. I strongly believed that the said St. Peter Life Plan Policy has
been inadvertently misplaced or lost without any malice or negligence on my part
whatsoever;

4. Despite all of these earnest efforts, I cannot locate the same. I therefore considered it lost and
beyond recovery;

5. I am executing this Affidavit to request St. Peter Life Plan Incorporated to issue me a new
Policy in lieu of the lost one. That, I hereby bind myself to fully excuse any person or
institution for any damage that it may incur for the issuance of the requested Policy;

6. Finally, I am executing this affidavit to attest to the truthfulness of the foregoing facts and for
all legal intents and purposes it may serve well.

IN WITNESS WHEREOF, I have hereunto set my hand this 3rd day of September 2018 at La
Trinidad, Benguet, Philippines.

ADELE OLIVE MARCELO

Affiant

SUBSCRIBED AND SWORN to before me a Notary Public for and in La Trinidad, Benguet,
Philippines this 3rd of September 2018 by the above Affiant exhibiting to me her valid ID and identified
by to be the same person who personally signed before me the foregoing Affidavit.

ATTY. CYRUS C. CALAYA

Doc. No. 403; Notary Public until Dec. 31, 2018
Page No. 81; PTR No. BGTCF5221777; Feb. 7, 2018
Book No. IV; IBP Lifetime No. 08051, at Pasig City
Series of 2018. Roll No. 52590, May 12, 2006; Manila
S & B Bldg., FA 224, Km. 4
National, Highway La Trinidad, Benguet