REPUBLIC OF THE PHILIPPINES )

Province of Davao del Norte )S.S

City of Tagum )
x---------------------x

AFFIDAVIT OF LOSS

I, NESTOR REPONTE MAMON, Filipino, single, of legal age, and a resident of Purok
4, Sta. Maria, Nabunturan, Davao de Oro, Philippines, after having been duly sworn to in
accordance with the law, do hereby depose and say THAT;

1. I am the owner/holder of SSS Unified Multi-Purpose ID (UMID), LTO Driver’s

License, BPI ATM Card and Landbank ATM Card, all issued under my name by the
respective issuing office and/or agency, which I safely kept in my wallet;

2. Sometime on June 14, 2021, upon returning home from the public market, I
discovered that my sling bag was partly open and my wallet, containing the foregoing items
and some bills and other IDs, which was placed in said sling bag, was no longer found;

3. Continuous and diligent search efforts were undertaken to locate my wallet and the
aforementioned contents, but the same was fruitless; thus, I now deemed my said UMID Card,
Driver’s License and ATM Cards as lost for all intents and purposes;

3. As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
and to apprise the proper authorities, particularly the SSS, LTO, Landbank, and BPI to
facilitate the replacement of the lost items, and for whatever legal purposes that this may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this _______________ at

_________________________, Philippines.

NESTOR REPONTE MAMON

Affiant

SUBSCRIBED AND SWORN to before me this _________________at

________________________, Philippines.

Doc. No. ____;

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