REPUBLIC OF THE PHILIPPINES)

PROVINCE OF LA UNION ) Ss.

MUNICIPALITY OF TUBAO )

AFFIDAVIT OF LOSS

KNOW ALL MEN BY THESE PRESENTS:

I, AVELINO N. NIEVA, of legal age, married, Filipino citizen and a resident of

Magsaysay, Tubao, La Union, after having been duly sworn to in accordance with law, do
hereby depose and state, that:

1. That I am a holder of a UMID ATM Card issued to me by the Government

Service Insurance System (GSIS), San Fernando City, La Union, PNB ATM
Card issued by Philippine National Bank (PNB), Agoo, La Union and Senior
purchase book issued by the Office for Senior Citizens Affairs (OSCA), Tubao,
La Union;

2. I used to place the aforesaid ATM cards, my Senior purchase book and Senior
purchase of book of my wife- LILIA S. NIEVA in my belt bag in the
compartment of my car for safekeeping;

3. Sometime on September 11, 2022, I discovered for the first time that said ATM
Cards and Senior purchase books which I’ve been keeping in my belt bag in the
compartment of my car were lost, possibly inadvertently misplaced, without my
knowledge or consent;

4. Diligent efforts were exerted to locate the same but failed, of which I presume
that the same is now lost and beyond recovery;

5. The said ATM Cards and Senior purchase books were not confiscated, revoked
or cancelled by any law enforcing authority or the issuing Government Service
Insurance System for violation of any laws, rules and regulations;

6. That I am executing this Affidavit to attest to the truth of all the foregoing facts
in support of my application for the issuance of new UMID ATM Card by the
Government Service Insurance System (GSIS), PNB ATM Card by the
Philippine National Bank (PNB) and Senior purchase books Office for Senior
Citizens Affairs (OSCA), Tubao, La Union by the and for all other legal intents
and purposes this may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this 12 th day of September

2022 at Tubao, La Union, Philippines.

AVELINO N. NIEVA
Affiant
Senior ID NO. 2509790

SUBSCRIBED AND SWORN to before me 12th September 2022 at Tubao, La

Union by the affiant appearing personally and who is known to me to be the same person
who executed this affidavit.

ATTY. JOONEE RANDYL E. RIVERA

Notary Public until December 31, 2022
Doc. No.: 209; Aspiras Highway, Francia Sur, Tubao, La Union
Page No.: 42; Roll No. 61766, TIN 929-347-628
Book No.: XXXIX; PTR No. 6677008, 01-03-22, Tubao, LU
Series of 2022. IBP Life Member No. 012553; 01-02-14, SFLU
Commission No. ANC-2020-70
MCLE No. VII-0004258, 07/21/21