Republic of the Philippines)

City of Cebu ) S.S.

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AFFIDAVIT OF LOSS

I, ALICIA TABOADA-DELA CERNA, Filipino, 83 years old, widow, and a

resident of 264 Katipunan Street, ISKP, Labangon, Cebu City, Philippines, after
having been duly sworn to in accordance with law, hereby depose and say:

1. On November 11, 2021 at about 4:00 P.M. in the afternoon, after I went to
Union Bank in Borromeo Street, Cebu City, I and a relative went to the
nearby Carbon Market to buy vegetables. Each time I bought a vegetable,
I took out my wallet from my bag to get money to pay. In my last
purchase, when I tried to search for my wallet inside my bag, I could not
find my wallet containing money and my GSIS funded Union Bank ATM
Card. We did our utmost search tracing back where we were but my
wallet could not anymore be found. I could be a victim of pickpocketing.

2. My Union Bank account number is 109593505177 and my GSIS ID No.

38062201514.

3. I am executing this affidavit for the purpose of having my Union Bank ATM
card replaced and for other legal purpose or purposes.

IN WITNESS WHEREOF, I have hereunto set my hand this _____ of

November 2021 in Cebu City, Philippines.

ALICIA TABOADA-DELA CERNA

Affiant
Senior Citizen Control No. 08862

SUBSCRIBED AND SWORN to before me this _____ of November 2021 in

Cebu City, Philippines, affiant personally known to me also exhibited to me
competent evidence of her identity the details of which are written below her name
above.

Doc No. ___________

Page No. __________
Book No. __________
Series of 2021.