REPUBLIC OF THE PHILIPPINES )

Province of Davao del Norte )S.S

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

AFFIDAVIT OF LOSS

I, JENNIFER ECHAVEZ RIMANDO, Filipino, married, of legal age, and a resident

of Maco, 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 holder/possessor of a CERTIFICATE OF OWNERSHIP OF ST. PETER

LIFE PLAN POLICY with LPA No. L12314846P and COFP No. CFPMET16-004460;

2. Sometime last week, I discovered that the said Certificate of Ownership was no
longer in my possession;

3. Thereafter, continuous and diligent search efforts were undertaken but the said
Certificate of Ownership could not be found; thus, the same is now deemed lost for all intents
and purposes;

4. I am executing this Affidavit of Loss to attest to the truth of the foregoing and for
whatever legal purposes that this may serve.

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

_________________________, Philippines.

JENNIFER ECHAVEZ RIMANDO

Affiant

SUBSCRIBED AND SWORN to before me this _________________at

________________________, Philippines.

Doc. No. ____

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