REPUBLIC OF THE PHILIPPINES )

Province of Davao del Norte )S.S

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

AFFIDAVIT OF LOSS

I, GRACE S. SILUD, Filipino, single, of legal age, and a resident of Purok 4,

Cabidianan, 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 the following personal effects all issued under my name by
the respective issuing office and/or agency, which I safely kept in our house, to wit:
(1) Landbank ATM Card;
(2) PhilHealth Identification Card;
(3) Pag-IBIG Identification Card;
(4) Transcript of Records;
(5) Diploma;
(6) LTO Student Permit;
(7) Birth Certificate; and
(8) Employee Identification Card

2. Last August 1, 2021, our house was engulfed by fire totally destroying all our
belongings including the aforementioned items and documents, thus, I now deem that
the same are 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 Landbank, PhilHealth, Pag-IBIG,
University of Mindanao-Tagum, LTO, PSA, and the Provincial Government of Davao
de Oro, 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.

GRACE S. SILUD
Affiant

SUBSCRIBED AND SWORN to before me this _________________at

________________________, Philippines.

Doc. No. _______;

Page No. _______;
Book No. _______;
Series of 20______.