REPUBLIC OF THE PHILIPPINES)

) S.S. 
                                                     
AFFIDAVIT OF LOSS
 
I, APPLE KHATE L. MONTEZA, of legal age, single, Filipino, with residence at
229 Sapphire St., San Antonio CAA, Las Pinas City, after having been sworn to in
accordance with law hereby depose and say that:

1. I am a member of Pag-IBIG and holder of Pag-IBIG ID with No. 1211-7889-

1044 issued by the Pag-IBIG Fund in Robinsons Las Pinas.

A copy of which is hereto attached as Annex “A”;

2. That on February 7, 2021, while I was riding a jeep going home, my card
holder was stolen by an unidentified person.

3. My said card holder contains my Pag-IBIG Loyalty Card and some valuable
Identification cards.

4. I took earnest efforts to locate the said card holder and even asked the
assistance of authorities, but to no avail.

5. I execute this affidavit to attest to the truthfulness and veracity of the

foregoing facts, and for the purpose of securing another Pag-IBIG Loyalty
Card in place of the stolen one, and for whatever purpose it may serve.

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

_________________________ in ____________________________________.                 
                   

                                                                    APPLE KHATE L. MONTEZA

Affiant                                           
        
 
      SUBSCRIBED AND SWORN to before me this _____ day of
_______________________ in ___________________________. Affiant exhibited to me his
competent evidence of identity as __________________.

Notary Public

Doc. No____;
Page No. ___;
Book No. ___;
Series of 2022.