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AFFIDAVIT OF LOSS OF CAR’S SIDE MIRRORS

Republic of the Philippines)

S.S.
City of Manila )

I, ______, Filipino citizen of legal age, single and residing at

_______________________________ after having been duly sworn to in
accordance with law, deposes and say:

1. That I am the _________________.

2. That the ___________________________.

3. _________________________.

4. That even ___________________o.

5. That _______________e
.
6. That I am executing this affidavit to attest to the fact of the loss of said car
side mirrors and for the purpose of recovering by way of indemnity the value of
the said side mirrors from my insurance company.

Further I sayeth none.

IN WITNESS WHEREOF, I hereunto affixed my signature this 12 th day of

May 2007 at the City of Manila, Philippines.
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SUBSCRIBED AND SWORN to before me this _____ day of May 2007 at

the City of Manila, Philippines, affiant exhibited to me her residence certificate no.
__________, issued at Manila, on _____________ 2007.

Notary Public

AFFIDAVIT OF LOSS

Republic of the Philippines)

S.S.
City of Manila )
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I, MARY MICHELLE QUINO, Filipino citizen of legal age, single and

residing at 850 Masbate St., Sampaloc, Manila, after having been duly sworn to in
accordance with law, deposes and say:

1. That I am a depositor of PCIB Ermita , Manila, with savings account no 00-

2113-30442-6.
2. That as such depositor I was given an ATM card which I used to withdraw or
deposit.
3. That I have been using such ATM card until March l7, l997 when my wallet
containing my said ATM card was lost on my way home aboard a jeepney
from school.
4. That my effort to locate my wallet with my ATM card proved futile.
5. That I am executing this affidavit to attest to the fact of this loss and for the
purpose of securing another ATM card.
Further I sayeth none.

IN WITNESS WHEREOF, I hereunto affixed my signature this 20 th day of

March l997 at the City of Manila.

MARY MICHELLE
QUINO
Affiant

SUBSCRIBED and SWORN to before me this __ day of March l997,

at the City of Manila, Philippines.

Notary Public
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AFFIDAVIT OF LOSS

REPUBLIC OF THE PHILIPPINES)

S.S.
CITY OF MANILA )

I, JANET Q. LAO, Filipino citizen of legal age, single and residing at 41 Carmel Ave.,
Carmel 2, Project 6, Quezon City, after having been duly sworn to in accordance with law, deposes
and say;

1. That I am an owner of a cellular mobile phone under Smart Communications, with no. 09l8-
8295510
2. That sometime on Sunday, March l6, l997, while I was shopping at S.M. Center point, I lost
my said cellular phone without my knowing where I place it.
3. That probably my said cellular phone was lost in the dry goods section when I was shopping for
my dress.
4. That my effort to locate the said cellular phone proved futile.
5. That I am executing this affidavit to attest to the fact of this loss and for other lawful purpose

Further I sayeth none.

IN WITNESS WHEREOF, I hereunto affixed my signature this 20th day of March at the City of
Manila, Philippines. .

JANET Q. LAO
Affiant

SUBSCRIBED AND SWORN to before me this _____ day of March l997 at the City of
Manila, Philippines.

Notary Public
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No,. 4l Carmel Ave. Project 6,

Quezon City
March 20, l997

The Smart Communications Inc.

Ground Floor, Rufino Bldg. Cor. Herrera & Ayala Ave.
Makati City

Re: Request for Disconnection of Line

Sir:

The undersigned subscriber would like to request that my cellular phone with no. 09l8-8295510 be
disconnected. This request is being made in view of the loss of my said cellular phone last March l6, l997 which
I did promptly report to your Office by phone.

Hoping this request merits your kind and favorable consideration.

Very truly yours

JANET Q. LAO

AFFIDAVIT OF LOSS
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REPUBLIC OF THE PHILIPPINES)

S.S.
CITY OF LAS PIÑAS )

I, Aldwin F. Alegre, Filipino citizen of legal age, single and residing at 220
Dapdap St. Casimiro Village 2 Pamplona III, Las Pinas City, after having been duly sworn to
in accordance with law, deposes and say;

1. That I applied for a Philippine passport for the first time last June 29, 2006 at
Department of Foreign Affairs in Pasay City for which I was issued a receipt with the
due date on July 3, 2006

2. That such receipt was lost together with my wallet sometime on July 2, 2006 when I was
robbed by armed men inside a Tamaraw Fx on my way home at about 7pm.

3. That my effort to recover my wallet together with the passport receipt from DFA proved
futile.

4. That I am executing this affidavit to attest to the fact of said loss and for the purpose
of claiming my passport without said receipt.

Further I sayeth none.

IN WITNESS WHEREOF, I hereunto affixed my signature this ____ day of July 2006
at the City of Las Piñas, Philippines. .

Aldwin F. Alegre
Affiant

SUBSCRIBED AND SWORN to before me this _____ day of July 2006 at the City of
Las Piñas , Philippines.

Notary Public