REPUBLIC OF THE PHILIPPINES)

CITY OF _____________ )S.S

x-------------------------------------------------x

JOINT AFFIDAVIT OF LOSS

We, AMALIA DELOS REYES RETOTAR, of legal age, married and a resident of Brgy 36,
Araniw, Laoag City, after having duly sworn to in accordance with law, hereby depose and say that:

1. I am the owner of a certain mobile phone having the mobile number 09158276660.

2. That on ______________________, I went to the Pag-IBIG office to remit contributions

of CAAP.

3. Thereafter, I immediately left the said office in order for me to accomplish transactions
with other government agencies. Because of the haste, I did not notice that I left my
mobile phone having the above-stated number.

4. Affiant exerted diligent efforts to locate the same but to no avail and we therefore
considered the same as lost and can no longer be found;

5. We are executing this Affidavit to attest to the truth of the foregoing facts and to use the
same for whatever legal purpose it may serve.

IN WITNESS WHEREOF, I hereunto affix my signature this ______________ at _______.

AMALIA DELOS REYES RETOTAR

Affiant

SUBSCRIBE AND SWORN TO BEFORE ME this __________________ at

____________________, affiant having exhibited to me his ____________________.

Doc. No. ____;

Page no. ____;
Book No. ____;
Series of 2020.