REPUBLIC OF THE PHILIPPINES )

PROVINCE OF MASBATE )
MUNICIPALITY OF SAN JACINTO ) S.S

AFFIDAVIT OF NON-RECEIPT

I, REMA M. DEJUMO, Filipino, of legal age and residing at Jones St.,

Población District II, San Jacinto, Masbate, after having been sworn according to
law, hereby depose and state that:

I. I purchased an insurance policy with policy number 000295525

from Beneficial Life Insurance Incorporated and designated my son,
MARK GABRIEL M. DEJUMO, as the beneficiary;

II. That said policy has been fully settled. Relative thereto, I have
requested a Certificate of Full Payment to no avail as it appeared
from their record that said instrument had already been issued;

III. That I have not received said instrument; and

IV. That this Affidavit has been executed to attest to the truth of the
foregoing facts for the purpose of securing said instrument
(Certificate of Full Payment for the Life Insurance Policy with
000295525).

REMA M. DEJUMO
Affiant

IN WITHNESS WHEREOF, I have unto set my hand this 31 st of May 2022, in

San Jacinto, Masbate, Philippines.
 SUBSCRIBED AND SWORN TO before me this 31st of May 2022 at San
Jacinto, Masbate, affiant REMA M. DEJUMO, personally appeared before me and
exhibited to me her Passport with ID No. P5040303A issued by DFA Legazpi
and is valid until November 12, 2022.

Notary Public

Doc. No.______;
Page No. ______;
Book No.______;
Series of 2022.