Republic of the Philippines )

CITY OF TACLOBAN . . . )ss.

x---------------x

AFFIDAVIT OF LOSS
I, AGUEZAR D. BALASANOS, Filipino, of legal age, single, and a resident of brgy. 43-A,
Quarry, Tacloban City, Philippines under oath declare:

1. That I am a member of the PAG-IBIG FUND and a holder of a PAG-IBIG ID Card with No.
1211-7847-6085;

1. That I usually keep the above card inside my wallet and place the same in my bag;

2. That sometime in 2021, I noticed that the wallet which contained the PAG-IBIG ID Card was
missing;

3. That I immediately exerted diligent efforts to locate the same but to no avail;

4. That said card has never been confiscated for violation of any law;

6. That I am executing this Affidavit of Loss to declare the truth of the foregoing and for
whatever legal purpose this may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this 16 th day of February 2022 in
Tacloban City, Philippines.

AGUEZAR D. BALASANOS
Affiant
ID No. 19-01-141
Issued by LGU-TAC

SUBSCRIBED AND SWORN to before me this 16th day of February 2022 in Tacloban City,
Philippines.

Doc. No. _____

Page No. _____
Book No. _____
Series of 2022.